Social Defeat and Psychotic Experiences in the United States: Findings from the Collaborative Psychiatric Epidemiological Surveys Hans Oh Submitted in partial fulfillment of the requirements for the Doctor of Philosophy under the Executive Committee of the Graduate school of Arts and Sciences COLUMBIA UNIVERSITY 2015 © 2015 Hans Oh All Rights Reserved ABSTRACT Social Defeat and Psychotic Experiences in the United States: Findings from the Collaborative Psychiatric Epidemiological Surveys Hans Oh Emerging studies have identified a specific kind of stress called social defeat, which occurs when a person is dominated, humiliated, and oppressed by another person or group. The sense of social defeat might play an important role in the development of psychosis. Meanwhile, scholars have increasingly studied the occurrence of Psychotic Experiences, which are expressions of psychosis that manifest in the general population without causing significant distress or functional impairment. Very few studies have examined the relationship between social defeat and Psychotic Experiences in the United States, and I utilize the Collaborative Psychiatric Epidemiological Surveys to examine whether and to what extent three facets of social defeat (everyday discrimination, major discriminatory events, and immigrant status) predict risk for Psychotic Experiences. In the first paper, I analyzed the National Latino and Asian American Survey and the National Survey of American Life, and found that among Latino-, Asian-, and Black- Americans, everyday discrimination was associated with increased risk for Psychotic Experiences in a dose-response fashion after adjusting for demographics and socioeconomic status. Discrimination perpetrated at the interpersonal level seems to impart a profound sense of defeat that raises risk for psychosis. In the second paper, I analyzed the National Survey of American Life and found that among Black Americans, certain major discriminatory events (being denied a loan, receiving unusually bad service, and police abuse) were associated with increased risk for Psychotic Experiences after controlling for demographics and socioeconomic status. Major events seem to capture a distal source of distress stemming from the institutions and structures of society, elevating risk for psychosis among Black Americans. In the final paper, I examined the National Comorbidity Survey Replication, the National Latino and Asian American Survey, and the National Survey of American Life, and found that immigration was not associated with increased risk for Psychotic Experiences in the United States, supporting the extant literature that suggests immigrants are paradoxically healthier than native-born populations. I discuss theoretical and practical implications of my findings, and present future directions for research. Table of Contents List of Tables and Figures iii Chapter I: Introduction Psychotic Experiences 1 Social Defeat 2 Discrimination 3 Immigration 4 References 6 Chapter II: Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States Introduction 11 Methods 13 Results 17 Discussion 23 References 28 Chapter III: Major discriminatory events are associated with increased risk for psychotic experiences among Black Americans Introduction 37 Methods 44 Results 49 Discussion 54 i References 57 Chapter IV: Immigration and psychotic experiences in the United States: Another example of the epidemiological paradox? Introduction 68 Methods 75 Results 78 Discussion 87 References 94 Chapter V: Conclusion Summary and Discussion of Results 106 Potential Limitations and Future Directions 107 Implications for social work practice 108 References 110 APPENDICES 112 ii Tables and Figures Chapter 1 Figure 1. Psychosis Continuum 1 Chapter 2 Table 1. Descriptive and bivariate comparisons of demographic and clinical variables 18 between respondents with and without PE Table 2. Descriptive and bivariate comparisons of discriminatory experiences between 19 respondents with and without PE Table 3. Multiple logistic regression models of associations between lifetime PE and 21 discrimination and covariates Figure 1. Discrimination and psychotic experience subtypes 22 Chapter 3 Table 1. Descriptive statistics of major discriminatory events and psychotic experiences 49 using completed cases Table 2. Descriptive statistics of major discriminatory events and subtypes of PE using 50 completed cases Table 3. Descriptive statistics of range of discriminatory events and psychotic experience 51 subtypes by ethnicity using completed cases Table 4. Bi-variable and adjusted logistic regression models depicting the impact of each 52 major discriminatory event on lifetime and 12-month psychotic experiences using completed cases Table 5. Bi-variable and adjusted logistic regression models depicting the impact of each 53 major discriminatory event on subtypes of psychotic experiences using completed cases Table 6. Adjusted logistic regression models depicting the associations between range of 54 general discrimination and PE using completed cases Chapter 4 Table 1. Descriptive data for migration variables and PE for each data set 79 Table 2. Demographic variables by each data set 80 Table 3. Multivariable logistic regression models depicting associations between 82 generational status and psychotic experiences in the National Comorbidity Survey - iii Replication Table 4. Multivariable logistical regression models depicting associations between 84 immigration and lifetime psychotic experiences among Latinos (N=2539) in the National Latino and Asian American Survey Table 5. Multivariable logistical regression models depicting associations between 85 immigration and lifetime psychotic experiences among Asians (N=2089) in the National Latino and Asian American Survey Table 6. Multivariable logistic regression models depicting associations between nativity 87 and lifetime psychotic experiences among Black Americans (N=4906) in the National Survey of American Life iv ACKNOWLEDGEMENTS I owe a debt of gratitude to many individuals for helping me complete this dissertation. Specifically, I would like to thank Ellen Lukens for sponsoring me, and Ada Mui for chairing my committee. I would also like to thank Fang-pei Chen, Jennifer Abe, and Jordan DeVylder for serving as committee members. Lastly, I would like to thank my family and friends for their love and support. v DEDICATION This is what the LORD says: Do what is just and right. Rescue from the hand of the oppressor the one who has been robbed. Do no wrong or violence to the foreigner, the fatherless or the widow, and do not shed innocent blood in this place. Jeremiah 22:3. vi Chapter I: Introduction Our understanding of psychosis has evolved over the past few decades into what we now conceptualize as a continuous phenotype that extends across a range of expressions. On the most severe end of the continuum is psychotic disorder, which causes significant distress and impairment in functioning. An example of a psychotic disorder is schizophrenia, which is rare and only occurs in about 1% of the US population. The middle region of the continuum consists of persistent psychotic symptoms, often emerging as features of non-psychotic mental illnesses. On the least severe end of the continuum are psychotic experiences (PE), which are attenuated hallucinations or delusions reported by ‘healthy’ people. PE are far more common than psychotic disorders and occur in upwards of 7.2% of the US population (Linscott & van Os, 2013). Most of the time PE are fleeting and innocuous; however, they do raise concerns. About 8-10% of those who report PE will develop a psychotic or non-psychotic disorder each year (Kaymaz et al., 2012), meaning PE have some predictive utility (Fisher et al., 2013; Werbeloff et al., 2012). Further, people with PE seem to seek treatment and perceive the need for help more than those who do not report PE (Armando et al., 2010; DeVylder et al., 2014a; Murphy et al., 2010; Oh et al., 2014; Yung et al., 2006), though distress associated with PE does not necessarily predict transition into disorder (Power et al., 2015). PE also co-occur with other psychiatric disorders (DeVylder et al., 2014), and are associated with suicide attempts among those with suicidal ideation (DeVylder et al., 2015). These negative outcomes compel researchers to examine the factors that increase risk for PE, and how these factors might inform prevention and early interventions. Proneness Persistence Impairment (Experiences) (Symptoms) (Disorders) Figure 1. The Psychosis Continuum 1