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Identity, perceived discrimination, and attenuated positive psychotic symptoms among college students

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Identity, perceived discrimination, and attenuated positive psychotic symptoms among college students

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Content Running Head: IDENTITY, PERCEIVED DISCRIMINATION, & APPS

Identity, Perceived Discrimination, and Attenuated Positive
Psychotic Symptoms Among College Students
Vanessa Calderon
Master of Arts (PSYCHOLOGY)
University of Southern California
August 2017

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Table of Contents

Abstract ………………………………………………………………………………………….. 2
Introduction ……………………………………………………………………………………… 3
Methods ………………………………………………………………………………………….. 8
Results ………………………………………………………………………………………..… 13
Discussion ……………………………………………………………………………………… 17
References ……………………………………………………………………………………… 23
Tables ………………………………………………………………………………………..…. 27
Figures ………………………………………………………………………………………..… 30
Appendices …………………………………………………………………………………...… 33

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Abstract
Previous studies have found a relationship between perceived discrimination and psychosis,
including attenuated psychotic symptoms. Many of these studies have been limited by their
operationalization of discrimination as a dichotomous variable and have not assessed the
influence of having multiple marginalized statuses. The present study addressed these concerns
by (1) replicating previous findings, (2) examining the double disadvantage hypothesis, which
suggests that greater marginalized statuses are associated with greater frequency of
discrimination, and (3) assessing whether perceived discrimination mediates the relationship
between the number of discriminated identities and attenuated positive psychotic symptoms
(APPS) within a college sample. Results were consistent with previous studies and found that
perceived discrimination is significantly predictive of APPS, while statistically adjusting for
depression and anxiety. Additionally, the number of discriminated identities was associated with
perceived discrimination and APPS. Finally, results indicated that perceived discrimination fully
mediates the relationships between the number of discriminated identities and APPS. These
findings indicate that individuals with multiple marginalized statuses may experience greater
discrimination, which is in turn predictive of greater APPS, suggesting a potential risk factor to
be further examined.
Keywords: perceived discrimination, identity, psychosis

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Introduction
It is an unfortunate truth that discrimination is highly prevalent in our society. According
to a recent national survey, nearly seven out of ten adults in the United States endorse
experiencing discrimination and 61% reported “day-to-day” discrimination (“Stress in America”,
2016). Concern over the ubiquity of discrimination is augmented by research that has
demonstrated an association between perceived discrimination and poor physical and mental
health status (e.g. Pascoe & Smart Richman, 2009).
Within the discrimination-health literature, it has been suggested that one mechanism
underlying this relationship is stress, particularly heightened physiological stress and more
negative psychological stress responses (Pascoe & Smart Richman, 2009). While a majority of
the literature has focused on mood and anxiety disorders or general psychological distress, the
conceptualization of discrimination as a psychophysiological stressor may have implications for
psychosis specifically. In particular, the social defeat hypothesis proposes that chronic
experience of social stressors may account for the increased risk for psychosis (Selten & Cantor-
Graae, 2005; Selten, van der Ven, Rutten, & Cantor-Graae, 2013). Animal models have
demonstrated that exposure to social defeat leads to sensitization and over-activity of the
mesolimbic dopamine system, which has been implicated in the development of psychosis
(Laruelle, 2003). While such experiments cannot be directly tested with human participants,
results from observational studies of discrimination and psychosis provide indirect support for
the social defeat hypothesis.
Studies conducted in Europe and the United States provide support for a relationship
between discrimination and psychotic experiences. This has been found among patients with
clinical psychosis (e.g. Veling, Selten, Susser, Laan, Mackenbach, & Hoek, 2007) as well as
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“subthreshold” experiences that do not necessarily meet clinical criteria for psychosis. For
example, a study of ethnic minorities in England found that self-reported experiences of racism
were associated with an increased risk for psychotic experiences (Karlsen, Nazroo, McKenzie,
Bhui, & Weich, 2005). In the United States, a study utilizing data from population-level surveys
found that high levels of perceived discrimination (when compared to no reported
discrimination) were associated with an increased likelihood of endorsing psychotic experiences
(Oh, Yang, Anglin, & DeVylder, 2014). A more recent study conducted with Black Americans
found that greater experiences of major discriminatory events (i.e. police discrimination) was
associated with higher risk for lifetime psychotic experiences (Oh, Cogburn, Anglin, Lukens, &
DeVylder, 2016).
Focusing on subclinical populations could be particularly important in elucidating the
relationship between discrimination and psychosis by being able to avoid some of the confounds
of assessing perceived discrimination among clinical populations, such as greater recall bias (if
asking them to recall discrimination experienced prior to the onset of their symptoms). Although
cross-sectional designs cannot determine a causal relationship, examining subthreshold or pre-
clinical symptoms may suggest that perceived discrimination can be considered a risk factor for
the development of psychosis. As such, the present study focuses on attenuated positive
psychotic symptoms (APPS). APPS are conceptualized as brief, positive psychotic symptoms
(e.g. delusions, hallucinations) that do not meet full threshold criteria for a clinical diagnosis
(Anglin et al., 2014). For example, perceptual disturbances (i.e. seeing unusual things like
flashes, flames, blinding light, or geometric figures) instead of the presence of hallucinations (i.e.
hearing voices). Recent studies have provided evidence that examining APPS could be
particularly informative. For example, a recent study of undergraduates from minority
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backgrounds found that racial discrimination was positively associated with APPS (Anglin,
Lighty, Greenspoon, & Ellman, 2014). Moreover, clinically, endorsing a significant number of
APPS can indicate that an individual is at greater risk for developing psychosis (Loewy,
Bearden, Johnson, Raine, & Cannon, 2005).
Limitations of the Current Literature
An important limitation of the current literature is that a majority of the research has
focused on single sources of discrimination, particularly based on racial or ethnic identity. Based
on the extant data and the social defeat hypothesis, it seems that individuals belonging to other
marginalized groups that experience discrimination (e.g. sexual minorities) are also vulnerable.
While limited research has examined distinct sources of discrimination in relation to psychosis, a
recent study found that lesbian, gay, and bisexual individuals showed elevated rates of one or
more psychotic symptoms compared to heterosexuals, which was partly mediated by experiences
of childhood trauma, bullying, and discrimination (Gevonden et al., 2014).
Furthermore, research in the area of discrimination and psychosis has yet to adequately
examine discrimination based on multiple marginalized identities. This is particularly relevant
considering the double disadvantage hypothesis, which suggests that individuals who hold more
than one marginalized status are at risk for poorer health outcomes (Dowd & Bengston, 1978).
Whereas research on the double disadvantage hypothesis has yielded mixed results, it has been
suggested that the risk is conferred not by the disadvantaged statuses themselves, but because of
greater experiences of discrimination due to the multiple disadvantaged statuses (Grollman,
2014). Along these lines, a prospective study conducted in the Netherlands found that the
number of discriminated identities (e.g. race and gender) endorsed at baseline was associated
with higher rates of delusional ideation, but no other psychotic symptoms, 3 years later (Janssen
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et al., 2003). However, when examining perceived discrimination as the number of “reasons” for
the discrimination (e.g. ethnicity, gender, age) Saleem and colleagues (2014) did not find an
association between the number of identities endorsed and attenuated psychotic symptoms
among a group of adolescents identified as being at clinical high risk for psychosis.
It is worth noting that some of the aforementioned studies utilized dichotomous variables
inquiring about lifetime experience of discrimination (e.g. Janssen et al., 2003; Saleem et al.,
2014). This is relevant because endorsing multiple discriminated identities does not necessarily
capture the frequency of discrimination experienced. A recent study demonstrated that
incorporating factors such as the number of discriminated identities as well as the frequency of
discrimination explained more of the variance of post-traumatic stress disorder symptoms than
looking at contextual factors (including racial minority status, living in high crime
neighborhoods, and trauma exposure) alone (Seng, Lopez, Sperlich, Hamama, & Reed Meldrum,
2012). Thus, a more comprehensive conceptualization of perceived discrimination that assesses
the frequency and level of distress may provide a more thorough assessment of the factors
contributing to the relationship between perceived discrimination and psychotic experiences, as it
has been demonstrated with other mental health issues (Grollman, 2014).
Present Study
This study addresses some of the aforementioned gaps in the literature; specifically, the
lack of attention to discrimination based on multiple identities and the role of the frequency of
the discrimination. I am interested in examining the relationship between perceived
discrimination and APPS among individuals that experience discrimination based on more than
one marginalized status.
Examining the potentially greater risks for psychotic experience among multiply
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discriminated adults will broaden our conceptualization of the discrimination-psychosis
relationship and provide us with a more nuanced understanding of this phenomenon.
Augmenting this body of research could help to identify which individuals may be at greater risk
of developing psychosis, which could in turn guide the development of prevention and early
intervention strategies for at-risk populations. Considering the prevalence of discrimination, it
seems that prevention and early intervention efforts in this area could confer significant benefits.
The present study aims to begin to explore whether the number of discriminated identities is
associated with the discrimination and attenuated psychotic symptoms.
In this study, I examined the relationships between discriminated identities, perceived
discrimination, and attenuated positive psychotic symptoms (APPS). First, I aimed to replicate
the association between perceived discrimination and APPS found in prior research (i.e. Anglin
et al., 2014) with a novel college aged sample. As my primary interest is examining the role of
the number of discriminated identities on the discrimination-APPS relationship, the present study
did not limit enrollment to racial/ethnic minorities as was the case in previous research. To
further examine whether the number of identities for which one was discriminated against was
predictive of APPS, additional analyses were conducted to examine this relationship. In other
words, I assessed if perceiving discrimination based on multiple marginalized statuses is
predictive of increased APPS. I hypothesized that more discriminated identities would be
associated with greater APPS. I was also interested in examining whether perceived
discrimination mediated this relationship (see Figure 1), and whether it held up when statistically
adjusting for other measures of distress - depression and anxiety.

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Methods
Participants
The present cross-sectional study was comprised of a series of self-report questionnaires
that were administered online. Undergraduate students were recruited from an introductory
psychology course at the University of Southern California through the department “subject
pool.” Students are required to complete a certain amount of research participant credits and
completion of the present survey contributed to this requirement. Participants had to be over the
age of 18. The study was conducted with undergraduate students for a couple of reasons. For
one, recruiting on a college campus could maximize the likelihood of reaching a racially diverse
population. Additionally, the typical undergraduate age range would increase the odds of
identifying individuals before they have experienced clinical psychosis since the median age of
onset of a psychotic disorder is around 22-23 (Jones, Rodgers, Murray, & Marmot, 1994;
Lauronen, Miettunen, Veijola, Karhu, Jones, & Isohanni, 2008). Furthermore, social valuation is
particularly salient during adolescence and young adulthood and prior research has found that
experiences of discrimination during this time have been associated with poor academic and
psychological outcomes (Huynh & Fuigni, 2010).
Measures
The primary constructs that were assessed were discriminated identities, perceived
discrimination, and APPS. Other variables that were measured include depressive and anxiety
symptoms as well as demographic information.
Demographics. Participants reported their age and education level (highest grade
completed). They were also instructed to indicate their race and ethnicity, sex, and gender. Self
and parent nativity was assessed by asking whether they/their parent was born outside of the US.
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Participants also specified their family household income by selecting one of the following
categories: (1) < 20,000; (2) 20–40,000; (3) 40–60,000; (4) 60–80,000; (5) 80–100,000; and (6)
> 100,000.
Perceived discrimination. Perceived discrimination was assessed with the Everyday
Discrimination Scale (EDS, Williams et al., 1997) (see Appendix A). The EDS contains 9 items
asking about day-to-day experiences of discrimination in different domains (e.g. being treated
with less respect than others, being threatened or harassed) and frequency (i.e. 0 – never, 1- less
than once a year, 2- a few times a year, 3 – a few times a month, 4 - at least once a week, 5 -
almost everyday). The endorsed frequency of discrimination for all items was summed to create
a perceived discrimination frequency score. Total scores can range from 0-45. The EDS has
demonstrated very good reliability with different minority populations (Clark, Coleman, &
Novak, 2004; Gonzales et al., 2016). In the present study, Cronbach’s alpha for the 9 item EDS
scale was 0.86.
Discriminated identities. Participants that responded “a few times a year” or more
frequently to at least one item on the EDS were asked to indicate the main reason(s) for those
experiences by selecting as many applicable “reasons” from a list. For the purposes of this study,
the “reasons” that participants endorsed are conceptualized as their “discriminated identities”.
The list of possible discriminated identities was adapted from the original scale to encompass
thematically grouped yet distinct aspects of identity. These include: your ancestry or national
origins, your gender, your race, your religion, your sexual orientation, some aspect of your
physical appearance, a mental illness, and/or a physical illness. Participants were also given the
option of selecting “something about you personally (e.g. personality) and/or “other”. As these
two options do not pertain to particular identities, these items were not included in the
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discriminated identities total score. Each identity listed could be marked as being “not at all” (0),
“somewhat” (1), or “very much so” (2) a reason for the experiences endorsed in the EDS. A total
score was derived based on the sum of the scores for each of the ten items. Scores can range
from 0-20. For example, if a participant selected “your race” as being “very much so” a reason
for their experiences and “your religion” as “not at all” applicable they would receive a total
score of 2. Cronbach’s alpha for the ten items that made up the discriminated identity score in
this study was 0.75.
Depression. Depressive symptoms were assessed with The Center for Epidemiologic
Studies Depression Scale (CES-D; Radloff, 1977) (see Appendix B). Participants rated whether
they had experienced 20 symptoms and their frequency within the past week (i.e. 0 – rarely or
none of the time, 1- some or a little of the time, 2- occasionally or a moderate amount of time, 3
– all of the time). Ratings were summed to obtain a total depressive symptom score, which
ranged from 0-60. The CES-D is a widely used tool that has shown good internal consistency as
well as concurrent and construct validity (Radloff, 1977). In the present study, Cronbach’s alpha
for the 20 CES-D items was 0.91.
Anxiety. Symptoms of anxiety were assessed with an abbreviated version of the Trait
Form-Anxiety Subscale of the State Trait Anxiety Inventory (STAI-trait) (Spielberger, Gorsuch,
Lushene, Vagg, & Jacobs, 1983), which was used in the study conducted by Anglin and
colleagues (2014) (see Appendix C). Items loading onto the depression factor were omitted, and
only items that load highly on the anxiety factor were administered. Loadings were derived from
a factor analysis study (Bieling, Antony, & Swinson, 1998). Participants rated how frequently
they experienced each anxiety symptom on a 4-point Likert scale. Ratings were summed to
obtain a total anxiety symptoms score. The range of scores is 0-28. The STAI-trait scale is a
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commonly used measure of anxiety that has demonstrated high discriminant and convergent
validity (Spielberger, 1983). Cronbach’s alpha for the 7-item modified STAI-trait scale used in
this study was 0.88.
Attenuated positive psychotic symptoms. APPS were assessed with the positive
symptoms subscale of the Prodromal Questionnaire-Likert (PQ; Loewy et al, 2007), which
includes 45 items asking about experiences of subthreshold positive psychotic symptoms within
the past month (see Appendix D). I focused on positive symptoms because they are generally
most predictive of which individuals are at high risk for developing psychosis (Loewy et al.,
2005). The PQ scale instructs participants to indicate the frequency of each symptom on a scale
(i.e. 0, 1-2 times, once a week, 2-3 times per week, daily). If an item is endorsed (i.e. rated
anything greater than 0), participants are asked to indicate whether or not the experience is
distressing. The total number of items endorsed was summed to create the APPS score. The
potential range of scores was 0-45.
The PQ is not intended to be used as a diagnostic tool on its own, rather the authors’
suggest it be used as a less time-intensive and less costly way to identify patients that should be
subsequently screened with comprehensive, validated clinical interviews. An original validation
study conducted with individuals seeking treatment for attenuated psychotic symptoms,
demonstrated good preliminary concurrent validity when compared to an established clinical
interview for prodromal psychosis (Loewy et al., 2005). The authors suggested a cut-off of 8 or
more positive symptoms. A follow-up study conducted with a non-clinical college sample
suggested a cut-off of 14 positive symptoms as well as consideration of the frequency and
“distress” ratings of the symptoms as well (Loewy et al., 2007). Cronbach’s alpha for the 45 item
positive symptoms subscale of the PQ questionnaire was 0.94 in the present study.
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Validity Checks. Two questions were included to assess whether participants were
actively engaging with questions or responding randomly. These included the following
questions: “What university do you attend” and “What state is your university located in?”. If a
participant responded incorrectly to either of these questions their responses to all items would
be omitted. No participants responded incorrectly to either of those questions.
Procedure
Participants had the opportunity to review and attest to an informed consent page prior to
beginning the survey items. All clinical scales were presented first, with the scale measuring the
dependent variable (APPS) being administered first so as to avoid any contamination from other
measures. Similarly, demographics were assessed last so as to avoid biasing respondents when
they reported on perceived discrimination and discriminated identities. No identifiable
information was collected. All study procedures were approved by the University of Southern
California’s Institutional Review Board.
Statistical Analyses
Pearson’s correlation analyses were used to examine bivariate relationships between
continuous APPS scores and other continuous measures, including perceived discrimination and
discriminated identities scores. These analyses served as a preliminary step in determining
whether relationships exist between the main study variables and warrant subsequent mediation
analyses. The same analyses were conducted for continuous APPS scores and continuous
demographic, anxiety, and depression variables, to determine whether these variables needed to
be statistically controlled for in the regression analyses. The relationships among APPS and
categorical demographic variables (i.e. race/ethnicity, gender) were assessed using one-way
ANOVAs.
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Analyses were conducted to examine an overall mediation model (see Figure 1). The first
analysis focused on the b path of the model and aimed to replicate results found in the literature
(Anglin et al., 2014), specifically the relationship between perceived discrimination and APPS
(when statistically adjusting for anxiety and depression) among college students. A hierarchical
linear regression was run to examine whether perceived discrimination significantly predicted
APPS while accounting for covariates. I hypothesized that there would be a significant positive
relationship between perceived discrimination and APPS.
Additional multiple linear regression analyses were then conducted to further examine
the c path of the model (see Figure 1) - the relationship between the number of discriminated
identities on APPS – beyond the bivariate analyses. I hypothesized that discriminated identities
would significantly predict APPS. In order to test the overall mediation model, the PROCESS
indirect bootstrapping macro for mediation for SPSS was used (Hayes, 2013). I hypothesized
that perceived discrimination would mediate the relationship between discriminated identities
and APPS. Finally, an additional mediation analysis that included covariates was conducted.
Results
Descriptive Statistics
Participant Demographics. A total of 305 individuals participated in the survey. Seven
participants completed less than half of the survey so their responses were omitted from analyses
leaving a final sample size of 298. Participant demographics are presented in Table 1. The
majority of participants identified as female (78.2%). The mean age was 19.78 years. A large
proportion of respondents were in their sophomore year of college (40.7%). The largest
ethnic/racial group represented was Asian (40.1%) followed by White (35%). A majority of
participants (55.1%) reported an annual household income above $100,000. Most respondents
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were born in the U.S. (76.3%) while 55.9% reported that their parents were born outside of the
U.S.
Discriminated Identities. On a scale ranging from 0-20, the mean discriminated
identities score was 5.34 (SD = 3.46). The most commonly endorsed identity was “some aspect
of your physical appearance” (73.1%) followed by gender (69.1%). The least endorsed identities
were a medical/physical illness (8.1%) and a mental illness (12.4%) (see Table 2).
Perceived Discrimination. A majority of the sample (86.6%) reported experiencing
discrimination at least once a year in a minimum of one domain. The most commonly endorsed
type of discrimination was “people act as if they’re better than you are” (80.3%). The least
endorsed item was “you are threatened or harassed” with 34.6% of the sample endorsing this
experience at any frequency.
Depression & Anxiety. In terms of depression symptoms as measured with the CES-D,
out of a maximum possible score of 60 the mean was 16.29 (SD = 10.12). The mean number of
anxiety symptoms on a scale out of 28 was 7.2 (SD = 5.22).
Attenuated Positive Psychotic Symptoms. The mean number of symptoms endorsed
was 14.89 (SD = 9.27) out of a possible 45. The most commonly endorsed symptoms included
“the passage of time felt unnaturally faster or slower than usual” with 91.2% of the sample
endorsing the item followed by “I have had difficulty organizing my thoughts or finding the right
words” with 87.6%. The least commonly endorsed items included “I have had experiences with
the supernatural astrology, seeing the future or UFOs” with 5.7% of the sample endorsing the
item and “I have seen things that other people apparently couldn’t see” with 7%.

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Correlations Among Variables
Bivariate analyses demonstrated significant relationships between the number of
identities endorsed and the reported frequency of perceived discrimination (r = .32, p < .05; see
path a in Figure 1), such that the more identities that were selected the greater perceived
discrimination was endorsed, as well as the association between perceived discrimination and
APPS (r = .40, p < .01; see path b in Figure 1). A significant association was also found between
the number of discriminated identities and APPS, providing evidence for the relationship
between the dependent and independent variables of interest in the present study (r = .17, p <
.01; see path c in Figure 1). Together, these findings supported conducting additional analyses to
test the mediation model. Anxiety and depression were also significantly associated with the
main study variables (i.e. number of discriminated identities, frequency of perceived
discrimination, and APPS) as well as with each other. No other significant relationships were
found between any demographic characteristics and APPS per bivariate correlation or one-way
ANOVA analyses. All correlation coefficients are presented in Table 3.
Regression And Mediation Analyses
In an effort to replicate prior literature, linear regression analyses were conducted to
further test the b path of my mediational model (see Figure 1), whether perceived discrimination
is positively associated with APPS when statistically adjusting for covariates. Results supported
my hypothesis and previous findings. Specifically, perceived discrimination significantly
predicted APPS when controlling for anxiety and depression (F(1, 300) = 45.54, p < 0.01).
Perceived discrimination accounted for 4% more of the variance in APPS than anxiety and
depression.
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Extending these results, additional multiple linear regression analyses were run to
examine the c path of my mediational model (see Figure 1) - whether the number of
discriminated identities predicts APPS. Results demonstrated that the number of discriminated
identities endorsed significantly predicted APPS (F(1, 294) = 8.737, p = 0.003) and accounted
for 2.9% of the variance.
After confirming that paths a, b, and c (see Figure 1) were significant per bivariate and
regression analyses, I assessed whether perceived discrimination mediates the relationship
between discriminated identities and APPS. Results from a mediation analysis using the
PROCESS macro (Hayes, 2013) demonstrated that perceived discrimination does mediate the
relationship between discriminated identities and APPS, point estimate = 0.33; 95% CI [0.18,
0.55], with r
2
= 0.03, a small effect size (see Figure 2). When perceived discrimination is entered
into the model, the direct effect between discriminated identities and APPS is no longer
significant (see Figure 2, path c’), point estimate = 0.12; 95% CI [-0.18, 0.42], suggesting full
mediation.
A final mediation analysis was conducted controlling for covariates, anxiety and
depression. The indirect effect was significant, point estimate = 0.15; 95% CI [0.06, 0.28], with
r
2
= 0.03, a small effect size, indicating that perceived discrimination mediates the relationship
between discriminated identities and APPS when statistically adjusting for anxiety and
depression (see Figure 3). As in the previous model, the direct effects (see path c’ Figure 1) were
not significant, point estimate =-0.002; 95% CI [-0.27, 0.27]. Additionally, the total effects (see
path c, Figure 3) were no longer significant, point estimate = 0.15; 95% CI [-0.12, 0.41].

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Discussion

Most individuals hold more than one identity, whether that be based on race, sexual
orientation, an illness, etc., which may in turn have implications for their risk of experiencing
discrimination. Extant research, however, has generally neglected to examine how multiple
identities play a role in the well-established relationship between discrimination and mental
health. In an effort to address this gap in the literature, the present study examined the
relationship between multiple discriminated identities and attenuated positive psychotic
symptoms (APPS).
Results of the present study support findings from previous studies, specifically Anglin
and colleagues (2014). The present study sample demonstrated a significant, positive relationship
between perceived discrimination and APPS when statistically adjusting for anxiety and
depression. It is worth noting that this was a diverse college sample, meaning discrimination was
not limited to a single “source” and participants endorsed an array of identities for which they
experienced discrimination. While previous studies identified a relationship between racial
discrimination and APPS, the present study indicates that discrimination due to a wider range of
marginalized identities is also associated with APPS. As such, these findings emphasize the
value of not limiting assessment of discrimination to a single identity.
Subsequent analyses extended the aforementioned finding by examining the role of
discriminated identities. It was found that the relationship between discriminated identities and
APPS is fully mediated by perceived discrimination. While this suggests that perceived
discrimination is driving the relationship between discriminated identities and APPS, it is
important to note that discriminated identities significantly predicts perceived discrimination. In
other words, the more discriminated identities that one holds the greater perceived discrimination
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they will experience. Thus, while it appears that it is perceived discrimination that is most
predictive of APPS, the number of discriminated identities does play a role in how much
discrimination they experience, which in turn predicts greater APPS. As such, having a greater
understanding of early risk factors could confer important implications for identification of
individuals that may be at-risk and preventative efforts. It is important to note that while it is
reasonable to assume that identities precede discrimination, given the cross-sectional nature of
the present study we cannot draw conclusions about causal or temporal relationships. The
significant results of the present study in combination with Anglin et al. (2014) provide evidence
for the existence of a relationship and suggest that additional longitudinal or experimental studies
may be warranted in order to provide further clarification on the nature of the relationships.
Furthermore, when covariates depression and anxiety were taken into account the direct
and total effects between discriminated identities and APPS were no longer significant.
Considering the significant correlations between all of the variables in this model, it is likely that
the pathways between the variables could be more complex than proposed in the present study.
For example, the number of identities that they perceive being discriminated against could
influence perceived discrimination which would in turn lead to distress that contributes to
anxiety which leads to greater APPS. As such, a next step could be to use structural equation
modeling with this data to further examine the nature of these relationships.
Within the relationship between perceived discrimination and psychosis, it is important to
consider the “cultural paranoia” that has been found among racial minorities, particularly
African-Americans (e.g. Whaley, 2002). This has been described as an adaptive response to the
racism and injustice disproportionately experienced by African-Americans (Ridley, 1984). It has
also been documented that African-Americans are more likely to receive a diagnosis of
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schizophrenia than whites, suggesting that clinicians may be over-pathologizing normative,
cultural distrust. In an effort to address the concern of pathologizing “healthy paranoia” in the
present study, I ran additional analyses excluding the paranoid symptoms on the Prodromal
Questionnaire (Loewy et al., 2007). In doing so I found the same overall pattern of results
1
,
suggesting that the relationship between discriminated identities, perceived discrimination, and
APPS is not driven by normative paranoia that is often observed among marginalized
populations.
It is also worth noting the small variance and effect sizes accounted for in these data. In
order to further explore the nature of the relationships between discriminated identities,
perceived discrimination and APPS, other potential correlates could be considered. For example,
it is possible that the total number of discriminated identities itself is not most predictive of
APPS but certain identities could be. Additionally, other factors such as the centrality or salience
of the identities could interact with experiences of discrimination and APPS. The influence of
centrality on the discrimination-heath relationship has been inconclusive, with research finding
both buffering and exacerbating effects (Yip, Gee, & Takeuchi, 2008). It is possible that for
individuals that endorse multiple discriminated identities, the centrality of each may be important
in determining whether and how they are affected by experiencing discrimination for one or
more of their identities. Another possibility is that the interaction between certain marginalized

1

1
Six ‘paranoia’ items were excluded from the 45-item PQ (see Appendix D). Bivariate analyses
demonstrated results consistent with those reported using the full PQ scale. Mediation analyses
excluding the paranoia items also demonstrated a consistent pattern, specifically perceived
discrimination mediated the relationship between discriminated identities and APPS when
statistically adjusting for depression and anxiety, point estimate = 0.12; 95% CI [0.05, 0.24],
r
2
=0.03.

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

20

identities could confer greater risk than others, however given the limited research in this area, it
is difficult to propose specific hypotheses regarding these relationships.
Together, the findings of the present study provide support for the social defeat
hypothesis (Selten & Cantor-Graae, 2005) as a potential mechanism by which to understand the
relationship between perceived discrimination and APPS. Given the literature on perceived
discrimination and other measures of psychological distress (e.g. depression) as well as the high
correlations between perceived discrimination and anxiety and depression in the present study,
future research should further examine the mechanisms underlying the relationships between
discrimination and mental health outcomes. It would be particularly beneficial to attempt to
understand the multifinality evidenced in the present study, and whether there are distinct
mechanisms that predict the development of psychosis versus another form of psychological
distress, such as depression. Incorporating biological markers could be particularly informative.
However, it is also important to keep in mind that these disorders often co-occur, and the high
degree of comorbidity between them could simply be reflective of the typical clinical
presentation.
Limitations
There are limitations of the present study that are worth noting. For one, the use of self-
report questionnaires, which could result in random or inaccurate responding. I attempted to
diminish this possibility by including the aforementioned validity check questions. Additionally,
given that discriminated identities and perceived discrimination were both assessed from a single
measure, it is possible that due to common-method variance the two intended variables were not
accurately captured as distinct constructs. Future studies can operationalize the variables in
multiple ways (e.g. clinician rating, interviews, etc.). Furthermore, listing the possible
IDENTITY, PERCEIVED DISCRIMINATION, & APPS

21

discriminated identities as a 3-point rating scale could have contributed to inflation of the
number of identities either by prompting participants to endorse an identity because it was listed
or by defaulting to the middle ‘1’ (i.e. “somewhat”) option.
Additionally, it is possible that individual perception may have played a role in the
findings. More specifically, it may be that the relationships observed between the identities,
perceived discrimination, and APPS could be a result of general “misperception”, reflected in
misperception of their surroundings (found in the APPS) and experiences (i.e. their perceived
discrimination). Similarly, the distorted perceptions found in psychosis could contribute to
misperceptions of interpersonal encounters, which could have contributed to high levels of
perceived discrimination that may not have been “true” incidences of discrimination. Future
studies should account for perception or introduce experimental manipulations to elucidate the
role of perception in the relationship between identities, perceived discrimination, and APPS.
It should also be noted that the high correlations between depression, anxiety, and APPS
could have influenced the findings in several ways. As indicated previously, it is possible that the
overall model of the relationships between these variables could be more complex than
hypothesized in the present study. Another possibility is that the multiple correlations could have
shrouded potential effects of discriminated identities on APPS. Furthermore, given the high
comorbidity of different mental illnesses that is seen clinically, it is possible that discriminated
identities and perceived discrimination present risk factors for general psychological distress and
an additional variable, unaccounted for in the present study, may be a stronger predictor of APPS
than those being assessed.
Conclusion
Results of the present study suggest that greater discriminated identities are associated
IDENTITY, PERCEIVED DISCRIMINATION, & APPS

22

with greater perceived discrimination. As perceived discrimination has been shown to predict
APPS in this and previous studies, the association with discriminated identities may confer
important clinical implications. As a potential risk factor, having multiple marginalized identities
suggests a potential intervention point. Increased support services for these individuals along
with campus-wide education regarding discrimination could be highly beneficial. Additionally,
the high rates of endorsement on the mental health measures in this study, emphasize the need
for mental health services and education on college campuses. Whether it is depression, anxiety,
or attenuated psychosis the results of the present study suggest that college students are
experiencing high levels of psychological distress and support services are crucial, particularly
for those that may be at risk for experiencing greater discrimination and distressing mental health
problems.
Through my research question and results, I aim to highlight the importance of
considering the complexity of how constructs such as identity and discrimination play out in real
life. To further understand this relationship, researchers must take a nuanced approach in
conceptualizing and empirically examining individual’s identities and how these interplay with
perceived discrimination. Moreover, given the paucity of research in this area future research
should assess the mechanisms by which discrimination may be associated with early indicators
of psychosis, which could confer opportunities for detection and early intervention strategies.
IDENTITY, PERCEIVED DISCRIMINATION, & APPS

23

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Table 1
Demographic Information
Mean (SD) n %
Age 19.78 (1.46) - -
Academic Year
Freshman 35 11.8
Sophomore 121 40.7
Junior 76 25.6
Senior 65 21.9
Gender
Male 64 21.5
Female 233 78.2
Transgender 1 .3
Ethnicity
Asian 119 40.1
Black or African-American 20 6.7
Hispanic/Latinx 26 8.8
Native Hawaiian or other Pacific Islander 3 1.0
White 104 35.0
Other 25 8.4
Place of birth
US 228 76.3
Outside of US 71 23.7
Parents place of birth
US 131 44.1
Outside of US 166 55.9
Annual Household Income ($)
< 20,000 17 5.8
20,000-40,000 27 9.2
40,000-60,000 23 7.9
60,000-80,000 28 9.6
80,000-100,000 36 12.3
> 100,000 161 55.1

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28

Table 2
Discriminated Identities Endorsed
n(%)
Identity “Not at all” “Somewhat” “Very Much So”
Ancestry 158 (53) 103 (34.6) 37 (12.4)
Gender 92 (30.9) 147 (49.3) 59 (19.8)
Race 123 (41.3) 116 (38.9) 59 (19.8)
Age 103 (34.6) 150 (50.3) 45 (15.1)
Religion 239 (80.2) 47 (15.8) 12 (4)
Physical Appearance 80 (26.8) 145 (48.7) 72 (24.2)
Sexual Orientation 259 (86.9) 24 (8.1) 13 (4.4)
Education/Income 159 (53.4) 101 (33.9) 38 (12.8)
Mental Illness 261 (87.6) 22 (7.4) 15 (5)
Physical Illness 274 (91.9) 13 (4.4) 11 (3.7)

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29

Table 3
Correlation Coefficients
Variable 1 2 3 4 5 6 7
1. APPS - .40** .17** .46** .51** -.10 .02
2. Perceived Discrimination .40** - .32* .35* .39* -.05 -.08
3. Discriminated Identities .17* .32* - .18* .22* -.01 -.18**
4. Depression .46** .35* .18* - .71** .00 -.15**
5. Anxiety .51** .39** .22** .71** - -.04 -.03
6. Age .10 -.05 -.01 .00 -.04 - -.14*
7. Income .02 -.08 -.15** -.15** -.03 -.14* -
*p < .05, **p < .01

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30

Figure 1. Model being tested in the present study: perceived discrimination will mediate the
relationship between discriminated identities and APPS.

Perceived
Discrimination
Discriminated
Identities
Attenuated
Positive Psychotic
Symptoms
a b
c
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31

Figure 2. Perceived discrimination mediates the relationship between discriminated identities
and APPS, * p < .05, ** p < .01.

Perceived
Discrimination
Attenuated
Positive Psychotic
Symptoms
Discriminated
Identities
(c = .46**)
c’ = .12
b = .52** a = .64 **
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32

Figure 3. Perceived discrimination mediates the relationship between discriminated identities
and APPS when statistically adjusting for depression and anxiety, * p < .05, ** p < .01.

Perceived
Discrimination

Discriminated
Identities (c = .15)
c’ = -.00
b = .30 ** a = .49**
Depression Anxiety
.14 *
.59 **
Attenuated
Positive Psychotic
Symptoms
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33

Appendix A
Everyday Discrimination Scale

In your day-to-day life, how often do any of the following things happen to you?

(Asked only of those answering “A few times a year” or more frequently to at least one
question.):
What do you think are the main reasons for these experiences? Select all that apply and
indicate the degree to which they were main reasons for your experiences.

Your Ancestry or National Origins
o Not at all
o Somewhat
o Very much so
Your Gender
o Not at all
o Somewhat
o Very much so
Your Race
o Not at all

Almost
everyday
At least
once a
week
A few
times a
month
A few
times a
year
Less
than
once a
year
Never
1. You are treated with less
courtesy than other people
are.

2. You are treated with less
respect than other people
are.

3. You receive poorer
service than other people at
restaurants or stores.

4. People act as if they
think you are not smart.

5. People act as if they are
afraid of you.

6. People act as if they
think you are dishonest.

7. People act as if they’re
better than you are.

8. You are called names or
insulted.

9. You are threatened or
harassed.

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

34

o Somewhat
o Very much so
Your Age
o Not at all
o Somewhat
o Very much so
Your Religion
o Not at all
o Somewhat
o Very much so
Some Aspect of Your Physical Appearance
o Not at all
o Somewhat
o Very much so
Your Sexual Orientation
o Not at all
o Somewhat
o Very much so
Your Education or Income Level
o Not at all
o Somewhat
o Very much so
A Mental Illness
o Not at all
o Somewhat
o Very much so
A Medical/Physical Illness
o Not at all
o Somewhat
o Very much so
Other (Please specify: ______________)
o Not at all
o Somewhat
o Very much so

Adapted from: Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial
differences in physical and mental health socio-economic status, stress and
discrimination. Journal of Health Psychology, 2(3), 335-351.

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

35

Appendix B
Center for Epidemiologic Studies Depression Scale (CES-D)

Below is a list of some of the ways you may have felt or behaved. Please indicate how often
you’ve felt this way during the past week. Respond to all items.

During the past week…
Rarely or
none of the
time
(less than 1
day)
Some or a
little of the
time
(1-2 days)
Occasionally
or a moderate
amount of
time
(3-4 days)
All of the
time
(5-7 days)
1. I was bothered by things that
usually don’t bother me.

2. I did not feel like eating; my
appetite was poor.

3. I felt that I could not shake off
the blues even with help from
my family.

4. I felt that I was just as good
as other people.

5. I had trouble keeping my mind
on what I was doing.

6. I felt depressed.
7. I felt that everything I did was
an effort.

8. I felt hopeful about the future.
9. I thought my life had been a
failure.

10. I felt fearful.
11. My sleep was restless.
12. I was happy.
13. I talked less than usual.
14. I felt lonely.
15. People were unfriendly.
16. I enjoyed life.
17. I had crying spells.
18. I felt sad.
19. I felt that people disliked me.
20. I could not "get going."

Source: Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the
general population. Applied Psychological Measurement, 1, 385-401.

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

36

Appendix C
State–Trait Anxiety Inventory – Trait Subscale

A number of statements which people have used to describe themselves are given below. Read
each statement and indicate how you feel right now, that is, at this moment. There are no right or
wrong answers. Do not spend too much time on any one statement but give the answer which
seems to describe your present feelings best.

Not at all Somewhat Moderately
so
Very much
so
1. Some unimportant thought runs
through my mind and bothers me

2. I worry too much over something
that really doesn't matter

3. I take disappointments so keenly
that I can't put them out of my mind

4. I feel that difficulties are piling up
so that I can't overcome them

5. I feel nervous and restless
6. I get in a state of tension or
turmoil as I think over my recent
concerns and interests

7. I have disturbing thoughts

Adapted from: Spielberger C. D., Gorsuch R. L., Lushene R., Vagg P. R., & Jacobs G. A.
(1983). Manual for the state–trait anxiety inventory. Consulting Psychologists Press, Palo Alto.

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

37

Appendix D
Prodromal Questionnaire-Likert (Positive Symptom Subscale)

Indicate how often you have had the following thoughts, feelings and experiences on average, in
the last month, by circling the appropriate answer on the scale for each item. Do not include
experiences while using alcohol, drugs or medications.

For any item response greater than 0, circle the word “distress” if that experience has been
distressing to you. Please answer all of the questions, and if you are unsure, choose the answer
that you think is best.

In the last month:

1. The passage of time has felt unnaturally faster or slower than usual.
0-----1-2 times-----once/week-----few times/week-----daily distress

2. I have had difficulty organizing my thoughts or finding the right words.
0-----1-2 times-----once/week-----few times/week-----daily distress

3. When I looked at a person, or at myself in a mirror, I have seen the face change right before
my eyes.
0-----1-2 times-----once/week-----few times/week-----daily distress

4. I have noticed strange feelings on or just beneath my skin, like bugs crawling.
0-----1-2 times-----once/week-----few times/week-----daily distress

5. Previously familiar surroundings have seemed strange, confusing, threatening or unreal.
0-----1-2 times-----once/week-----few times/week-----daily distress

6. I seemed to live through events exactly as they happened before (déjà vu).
0-----1-2 times-----once/week-----few times/week-----daily distress

7. I have smelled or tasted things that other people didn't notice.
0-----1-2 times-----once/week-----few times/week-----daily distress

8. I have thought that other people could read my mind.
0-----1-2 times-----once/week-----few times/week-----daily distress

9. I have heard things other people couldn't hear like voices of people whispering or talking.
0-----1-2 times-----once/week-----few times/week-----daily distress

10. I have heard unusual sounds like banging, clicking, hissing, clapping or ringing in my ears.
0-----1-2 times-----once/week-----few times/week-----daily distress

11. I have mistaken shadows for people or noises for voices.
0-----1-2 times-----once/week-----few times/week-----daily distress
IDENTITY, PERCEIVED DISCRIMINATION, & APPS

38

12. Things have appeared different from the way they usually do (brighter or duller, larger or
smaller, or changed in some other way).
0-----1-2 times-----once/week-----few times/week-----daily distress

13. I have wandered off the topic or rambled on too much when I was speaking.
0-----1-2 times-----once/week-----few times/week-----daily distress

14. I have had experiences with telepathy, psychic forces, or fortune-telling.
0-----1-2 times-----once/week-----few times/week-----daily distress

15. I have thought that other people had it in for me.
0-----1-2 times-----once/week-----few times/week-----daily distress

16. My sense of smell has seemed unusually strong.
0-----1-2 times-----once/week-----few times/week-----daily distress

17. I have felt that I was not in control of my own ideas or thoughts.
0-----1-2 times-----once/week-----few times/week-----daily distress

18. I have thought that I am very important or have abilities that are out of the ordinary.
0-----1-2 times-----once/week-----few times/week-----daily distress

19. My thoughts have seemed to be broadcast out loud so that other people knew what I was
thinking.
0-----1-2 times-----once/week-----few times/week-----daily distress

20. I have felt unusually sensitive to noise.
0-----1-2 times-----once/week-----few times/week-----daily distress

21. I have had superstitious thoughts.
0-----1-2 times-----once/week-----few times/week-----daily distress

22. I have heard my own thoughts as if they were outside of my head.
0-----1-2 times-----once/week-----few times/week-----daily distress

23. I have had trouble focusing on one thought at a time.
0-----1-2 times-----once/week-----few times/week-----daily distress

24. I have felt that other people were watching me or talking about me.
0-----1-2 times-----once/week-----few times/week-----daily distress

25. I have thought that things I saw on the TV or read in the newspaper had a special meaning
for me.
0-----1-2 times-----once/week-----few times/week-----daily distress

IDENTITY, PERCEIVED DISCRIMINATION, & APPS

39

26. My thinking has felt confused, muddled, or disturbed in some way.
0-----1-2 times-----once/week-----few times/week-----daily distress

27. I have felt suddenly distracted by distant sounds that I am not normally aware of.
0-----1-2 times-----once/week-----few times/week-----daily distress

28. I have had the sense that some person or force was around me, even though I could not see
anyone.
0-----1-2 times-----once/week-----few times/week-----daily distress

29. I have been worried that something may be wrong with my mind.
0-----1-2 times-----once/week-----few times/week-----daily distress

30. I have felt that I didn't exist, the world didn’t exist, or that I was dead.
0-----1-2 times-----once/week-----few times/week-----daily distress

31. I have been confused whether something I experienced was real or imaginary.
0-----1-2 times-----once/week-----few times/week-----daily distress

32. I have experienced unusual bodily sensations such as tingling, pulling, pressure, aches,
burning, cold, numbness, shooting pains, vibrations or electricity.
0-----1-2 times-----once/week-----few times/week-----daily distress

33. I have thought about beliefs that other people would find unusual or bizarre.
0-----1-2 times-----once/week-----few times/week-----daily distress

34. I have felt that parts of my body had changed in some way, or that parts of my body were
working differently than before.
0-----1-2 times-----once/week-----few times/week-----daily distress

35. My thoughts have been so strong that I could almost hear them.
0-----1-2 times-----once/week-----few times/week-----daily distress

36. I have seen special meanings in advertisements, shop windows, or in the way things were
arranged around me.
0-----1-2 times-----once/week-----few times/week-----daily distress

37. I have picked up hidden threats or put-downs from what people said or did.
0-----1-2 times-----once/week-----few times/week-----daily distress

38. I have used words in unusual ways.
0-----1-2 times-----once/week-----few times/week-----daily distress

39. I have felt that some person or force interfered with my thinking or put thoughts into my
head.
0-----1-2 times-----once/week-----few times/week-----daily distress
IDENTITY, PERCEIVED DISCRIMINATION, & APPS

40

40. I have had experiences with the supernatural, astrology, seeing the future or UFOs.
0-----1-2 times-----once/week-----few times/week-----daily distress

41. People have dropped hints about me or said things with a double meaning.
0-----1-2 times-----once/week-----few times/week-----daily distress

42. I have been concerned that my closest friends and co-workers were not really loyal or
trustworthy.
0-----1-2 times-----once/week-----few times/week-----daily distress

43. I have seen unusual things like flashes, flames, blinding light, or geometric figures.
0-----1-2 times-----once/week-----few times/week-----daily distress

44. I have seen things that other people apparently couldn’t see.
0-----1-2 times-----once/week-----few times/week-----daily distress

45. People have found it hard to understand what I say.
0-----1-2 times-----once/week-----few times/week-----daily distress

Adapted from: Loewy R. L., Johnson J. K., & Cannon T. D. (2007) Self-report of attenuated
psychotic experiences in a college population. Schizophrenia Research, 93(13), 144–151.

Note. “Paranoia” items have been bolded.

Abstract (if available)

Abstract Previous studies have found a relationship between perceived discrimination and psychosis, including attenuated psychotic symptoms. Many of these studies have been limited by their operationalization of discrimination as a dichotomous variable and have not assessed the influence of having multiple marginalized statuses. The present study addressed these concerns by (1) replicating previous findings, (2) examining the double disadvantage hypothesis, which suggests that greater marginalized statuses are associated with greater frequency of discrimination, and (3) assessing whether perceived discrimination mediates the relationship between the number of discriminated identities and attenuated positive psychotic symptoms (APPS) within a college sample. Results were consistent with previous studies and found that perceived discrimination is significantly predictive of APPS, while statistically adjusting for depression and anxiety. Additionally, the number of discriminated identities was associated with perceived discrimination and APPS. Finally, results indicated that perceived discrimination fully mediates the relationships between the number of discriminated identities and APPS. These findings indicate that individuals with multiple marginalized statuses may experience greater discrimination, which is in turn predictive of greater APPS, suggesting a potential risk factor to be further examined.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Calderon, Vanessa (author)

Core Title Identity, perceived discrimination, and attenuated positive psychotic symptoms among college students

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 08/01/2017

Defense Date 04/18/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag attenuated psychosis,identity,OAI-PMH Harvest,perceived discrimination

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lopez, Steven (committee chair), Huey, Stanley (committee member), John, Richard (committee member)

Creator Email calderov@usc.edu,v.calderon91@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-420840

Unique identifier UC11264084

Identifier etd-CalderonVa-5669.pdf (filename),usctheses-c40-420840 (legacy record id)

Legacy Identifier etd-CalderonVa-5669.pdf

Dmrecord 420840

Document Type Thesis

Rights Calderon, Vanessa

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA