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CONCEPTUALIZING THE RELATIONSHIP BETWEEN 
RACISM AS A PSYCHOSOCIAL STRESSOR AND THE 
DISPROPORTIONATE RATES OF SCHIZOPHRENIA 
AMONG BLACK AMERICANS USING THE DIATHESIS-
STRESS MODEL

KASHONDA L. DAVIS

ABSTRACT
Schizophrenia is classified as one of the most debilitating mental 

health disorders due to the chronicity of symptoms and the magnitude of 
impairments in multiple domains of the individual’s life (Shetty & Bose, 2014). 
Research has consistently demonstrated that Black Americans, in comparison 
to other racial groups, have the highest prevalence rates of schizophrenia. With 
a paucity of empirical evidence ascertaining the etiology of schizophrenia, 
many scholars assert that elevated levels of stress play a critical role in the 
development of the disorder. This paper draws upon the diathesis-stress 
model to elucidate a relationship between significant levels of stress endured 
by Black Americans due to racism and their elevated rates of schizophrenia. 
The presented argument calls for further research on the impact of racism on 
Black Americans’ disproportionately high rates of schizophrenia diagnoses.

INTRODUCTION
Racism is the menace embedded into the fabric of American culture 

interlaced with the propensity of predation for-profit and subjugating 
groups of color to perpetuate privilege in another. Historically, Black 
Americans have been the victims of its objective to denigrate, discriminate, 
and systemically disenfranchise the race as a whole, resulting in assaults 
to their bodies and the psyche (Utsey & Payne, 2000). In recent years, the 
invisible wounds of racism on the Black American psyche have been studied 
to elucidate a relationship with health disparities in their community 
(Clark, Anderson, Clark, & Williams, 1999). Of the many health conditions 
exacerbated by psychosocial stress and overrepresented among Black 
Americans, schizophrenia is identified to have especially significant 
implications on the person’s life (Bresnahan et al., 2007).  Schizophrenia 
is defined as a complex multidimensional psychotic syndrome, marked 
by hallucinations, delusions, affective dysregulation, blunted affect, 
interpersonal functioning, and impaired cognition (Van Os, Kenis, & 
Rutten, 2010; Wykes, Moghaddam, & Silverstein, 2013). Black Americans 
are diagnosed with schizophrenia three to five times more than their White 
counterparts and have the highest prevalence rates in the U.S (Mueser & 
McGurk, 2004; Schwartz & Blakenship, 2014). 

While schizophrenia contains a genetic component, its onset is heavily 
influenced by the presence of environmental factors. Social defeat, a type 



COLUMBIA SOCIAL WORK REVIEW, VOL. 18 | 28 

of social stress, has been specifically studied because of its influence on the 
etiology of schizophrenia, which has been consistently replicated in animal 
studies (Moran et al., 2016). Social defeat refers to the defeated feelings of 
subordination after experiencing an adverse social encounter (Moran et al., 
2016). Social defeat may be triggered by a variety of racist processes that 
subjugate Black Americans to feelings of inferiority (Williams & Williams-
Morris, 2000). Perceptions of subjugation and discrimination among Black 
Americans have been linked to higher levels of psychological distress, 
life dissatisfaction, and acts as an underlying mechanism for psychosis 
(Williams & Williams-Morris, 2000; Van Winkel, Stefanis, & Myin-
Germeys, 2008). A 2015 Kaiser Family Foundation survey highlighted the 
distress experienced from social defeat, with results detailing that a third of 
Black Americans have been denied opportunities in employment or housing 
based on racial discrimination (DiJulio, Norton, Jackson, & Brodie, 2015). 
More than half of Black Americans report some connection to the prison 
system that includes being incarcerated themselves or knowing someone 
who has, and 45% indicated that at some point in life fearing that their life 
was in danger due to their race (DiJulio, Norton, Jackson, & Brodie, 2015).   

 In summary, Black Americans face disproportionately high levels of 
stress. A possible explanation is that racism causes Black Americans to 
experience social defeat and noxious psychological stress, which have been 
strongly linked to the onset of schizophrenia. This paper calls for future 
research to further examine this relationship between racism experienced 
by Black Americans and the higher rates of schizophrenia found in this 
community.

THE DIATHESIS-STRESS MODEL
Researchers suggest that all individuals have a level of vulnerability for 

mental disorders, but the degree of stress experienced by their environment 
plays a key role in their overall susceptibility (Abela & Hankin, 2005). The 
American Psychological Association has identified perceived discrimination 
as pivotal in contributing to chronic stress and health disparities amongst 
people of color (American Psychological Association, 2016). Van Os, Kennis, 
and Rutten (2010) suggest that holding a minority group position increases 
the risk of psychotic disorders. Collectively, various sources demonstrate 
that the stresses of racism make Black Americans more vulnerable to several 
psychiatric and physiological conditions. The impact of this stress is best 
understood through the framework of the diathesis-stress model.

The diathesis-stress model was initially developed to describe the 
etiology of schizophrenia when emerging evidence demonstrated that the 
disorder is a product of gene-environment interaction (McCutcheon, 2006). 
The diathesis-stress model posits that an individual with a predisposition to 
a specific disorder will be more likely to develop the disorder in the presence 
of adverse environmental stimuli inducing stress (Linehan, 1993). The 
diathesis to schizophrenia is supported by genetic mapping, which yields 



29 | COLUMBIA SOCIAL WORK REVIEW, VOL. 18 

heritability estimates of 79-83% (Green, Girshkin, Teroganova, & Quidé  
(2004); Hilker et al., 2018). However, heritability functions as a limited index 
in the etiology of schizophrenia unless it is viewed within the context of 
interaction with social effects (Van Os, Kenis, & Rutten, 2010). Twin studies 
investigating the genetic influence of schizophrenia in patients with the 
disorder have found that genes account for no more than 50% of the etiology, 
which suggests that an individual’s environment is a critical factor (Moran 
et al., 2016).

PERCEIVED RACISM AND EXPERIENCED RACISM 
ELICIT DELETERIOUS STRESS

The anticipation of discrimination has the potential to increase an 
individual’s vigilance for mistreatment, resulting in interracial mistrust, 
negative emotions, and depleted cognitive resources (Sawyer, Major, Casad, 
Townsend, & Mendes,., 2012). Persistent vigilance induced by mistrust 
prolongs evoked stress, causing deleterious effects on mental health 
(Sawyer et al., 2012).  The “Stress in America: The Impact of Discrimination” 
survey conducted by the American Psychological Association (APA) 
shows that 76% of Black Americans report having experienced “everyday 
discrimination,” such as being treated with less respect or being viewed as 
less intelligent (American Psychological Association, 2016). The perception 
of being prejudged or devalued, or the anticipation of discrimination evokes 
emotional distress signaling the body’s stress response (Sawyer et al., 
2012). The APA survey demonstrated Black and Hispanic participants also 
experience stress based on the anticipation of discrimination. For example, 
these demographics often feel a necessity to make a concerted effort on 
their appearance in order to receive good service at public establishments 
(American Psychological Association, 2016) The conscious effort exerted 
to prepare for forms of discrimination, and an individual’s experience of 
perceived discrimination, is a cognitive appraisal of threat, harm, or danger 
(Clark et al., 1999). A perceived threat initiates a stress response by the 
sympathetic nervous system, prompting it to mobilize the brain and body’s 
resources for safety (Sawyer et al. 2012; Clark et al., 1999).

ACTIVATION OF THE STRESS RESPONSE
The activation of the sympathetic nervous system is a response to 

sensory processing of stressful stimuli causing the hypothalamic-pituitary-
adrenal (HPA) axis to secrete neurotransmitters, enzymes, and hormones 
in preparation for a threat (Pruessner et al., 2016). Anticipating the self as a 
target of discrimination or prejudice is a potential stressor that activates the 
HPA axis to exercise the release of hormones that prepare for defense against 
the threat (Sawyer et al., 2012). This biological reaction is often automatic 
and unconscious to perceived threats in our environment and functions as 
a fundamental survival mechanism in preparation of defense (Pruessner, 
Cullen, Aas, & Walker, 2016)  During instances of stress, individuals will 



COLUMBIA SOCIAL WORK REVIEW, VOL. 18 | 30 

notice an elevated heart rate, muscle tension, and a sudden increase in 
energy due to cortisol being released into the bloodstream (American 
Psychological Association, 2019). However, after exposure to chronic stress, 
such as the stress Black Americans experience with racism, the fidelity of the 
sympathetic nervous system’s response to stress is suppressed (American 
Psychological Association, 2019;  Clark et al., 1999). When confronted with 
stress, the sympathetic nervous system releases glucocorticoids and cortisol 
(Pruessner et al., 2016). The release of glucocorticoids and cortisol is salient 
in the performance of the sympathetic nervous system’s ability to prepare 
for threats and restoring homeostasis (Pruessner et al., 2016)

  Glucocorticoids (cortisol in humans) and adrenocorticotropic 
hormones (ACTH) are two of the hormones released during this process 
and have been highly researched in relation to the adverse effects they have 
on the brain’s structure and functioning (Pruessner et al. 2016; Gubba, 
Netherton, & Herbert, 2000). Relative to schizophrenia, glucocorticoids 
have been found to modify neural functioning and elevate neurotransmitter 
systems activity, which is implicated in the pathophysiology of psychosis— a 
defining characteristic of the disorder (Pruessner et al., 2016; Stahl, 2013). 
Additionally, cortisol levels are found to be increased in individuals with 
schizophrenia compared to control groups without the disorder (Green et 
al., 2014). The continuous activation of the sympathetic nervous system and 
increased secreted hormones as a response to perceived and experienced 
racism is a sophisticated process that can induce the expression of a genetic 
vulnerability to schizophrenia (Green et al., 2014; Sawyer et al., 2012).  While 
empirical research on the neurophysiology of schizophrenia is compelling, 
future research should be directed towards measuring the magnitude of 
stress related to racism on cortisol levels in individuals with a predisposition 
to schizophrenia.

CLINICIAN BIAS IN THE DIAGNOSIS  
OF SCHIZOPHRENIA

To date, researchers have been unable to empirically verify explanations 
regarding Black Americans’ overrepresentation of schizophrenia (Schwartz 
& Blankenship, 2014). A compelling argument that dominates the literature 
base is clinician biases and lack of cultural competence (Schwartz & 
Blankenship, 2014). Professional standards of care require clinicians to 
assign diagnoses based upon maladaptive patterns of clinically significant 
emotional, psychological, and cognitive disturbances that yield distress 
or disability (Schwartz & Blankenship, 2014). Instead, research on racial 
influence in diagnostic evaluation supports that clinical measures used were 
developed with Euro-American samples, which present a discrepancy when 
applying the measure to a different race that varies in clinical presentation 
(Schwartz & Blankenship, 2014). A review by Neighbors et al. (1989) found 
misdiagnosis of disorders is often the result of a clinician’s lack of sensitivity 
to cultural variances that are portrayed in the patient’s psychopathology. In 



31 | COLUMBIA SOCIAL WORK REVIEW, VOL. 18 

Schwartz, Docherty, Najolia, and Cohen’s 2019 study of racial diagnostic 
biases, Black American participants were diagnosed with schizophrenia 
at higher rates when assessed by White clinicians due to variances in 
linguistic style. The authors suggest that these variances influenced 
elevated schizophrenia diagnoses, which are aligned with prior research 
documenting notable phonological and linguistic styles in Black American 
culture (Schwartz et al., 2019; Wyatt, 1995). Schwartz et al. (2019) provide 
empirical evidence of how cultural differences and insensitivity influence 
misdiagnosis. 

Differences in social norms and communication processes can lead 
to miscommunication, mistrust, attributional ambiguity, and heightened 
vigilance amongst minorities in the diagnostic process (Olbert, Nagendra, & 
Buck, 2018). Accordingly, Eack, Bahorik, Newhill, Neighbors, & Davis (2012) 
found that mistrust and clinician-perceived dishonesty was the strongest 
predictor of schizophrenia diagnoses among Black American participants, 
which increased the likelihood by one and half times of the sample group 
being diagnosed with schizophrenia.

 Clinicians make the assumption that psychopathology is presented 
similarly and are unaware that the disorder can differ in a clinical presentation 
based upon race and culture (Strakowski et al. 2003). Additionally, Schwartz 
and Blankenship (2014) note that the assignment of psychiatric diagnosis 
is influenced by personal perceptions or stereotypes held by the clinician. 
However, without the clinician observing their obligation to test these 
forms of judgments, coupled with their lack of consideration for whether 
or not the individual is operating within their cultural norms, misdiagnoses 
are promoted (Schwartz & Blankenship, 2014). Gara, Minsky, Silverstein, 
Miskimen, & Strakowski (2019) posit that schizophrenia is a diagnosis 
made by exclusion of criteria, and often Major Depressive Disorder (MDD) 
is not ruled out. Instead, clinicians under-diagnose MDD and bipolar 
disorder or subjectively overemphasize deviant behavior and associate 
it with schizophrenia (Gara et al., 2019; Schwartz & Blankenship, 2014).  
Misdiagnosis of schizophrenia among Black Americans was further 
investigated in a study by Strakowski et al. (2003). The study uncovered 
a discrepancy in diagnoses among Black American participants that were 
assessed in-person versus assessments conducted by a different clinician 
using a transcript that concealed the ethnicity of participants (Strakowski 
et al., 2003). Results from the study yielded inflation of schizophrenia-
spectrum diagnoses for Black Americans participants (Strakowski et al., 
2003). These studies’ findings support clinicians’ lack of uniformity in the 
diagnostic process and an overemphasis of certain symptomatology when 
assessing Black Americans. Empirical evidence on biases exercised in 
psychiatric care such as Strakowski et al. (2003), advances the notion of 
race playing a critical role in social and health disparities.



COLUMBIA SOCIAL WORK REVIEW, VOL. 18 | 32 

PROPELLING RESILIENCY WITH ADAPTIVE  
COPING MECHANISMS

The role of clinician deficits in cultural competence contributing 
to the diagnostic inflation of schizophrenia amongst Black Americans 
presents an alternative hypothesis to the diathesis-stress model. 
However, both explanations share the basis that racism is a salient factor 
in the disproportionate rates of schizophrenia diagnoses amongst Black 
Americans. For Black Americans, racism is an everyday, chronic experience 
that results in adverse consequences to the psychological and somatic well 
being of a person (Utsey & Payne, 2000). 

Researchers emphasize the importance of mitigating the stress of 
racism with adaptive coping mechanisms (Utsey & Payne, 2000; Pittman, 
2011). Historically, Black Americans have been forced to use passive forms of 
coping, such as avoidance, withdrawal, silence, or laughter (Pittman, 2011). 
These coping styles have been shown to exacerbate stress, induce anger, 
decrease life satisfaction, and lower self-esteem. Clinicians can influence 
the health outcomes of race-related stress by equipping individuals with a 
broader, more adaptive set of coping mechanisms. As specialists in mental 
health, clinicians can influence the health outcomes of race-related stress 
by equipping individuals with adaptive coping mechanisms. One example 
is the practice of mindfulness, defined as deliberate and nonjudgmental 
attentiveness to present-moment experiences (Shallcross & Spruill, 2018). 
Mindfulness is antithetical to passive coping responses such as avoidance 
and withdrawal (Shallcross & Spruill, 2018). This process of awareness is 
a vital tool to incorporate into therapy when engaging clients’ relaxation 
response. (Edenfield & Saeed, 2012). Mindfulness exercises help the 
individual to build an awareness of their psychophysiological response to 
racist events. (Shallcross & Spruill, 2018). As a result, Black Americans 
clients can better understand their experience of discrimination and how 
it impacts their sense of self-worth while simultaneously reducing their 
biological sensitivity to threats (Shallcross &Spruill, 2018).

Another possibility for clinicians is to employ the Racial Trauma 
Recovery model proposed by Comas-Diaz (2015). The model details a five-
stage process for combating race-related stress. The model provides safety 
in openly discussing the racist event, teaches self-regulation, reprocesses 
the event, fosters resilience through psychological decolonization, and 
promotes engaging in social action.  

Social work clinicians represent the majority of mental health 
professionals, making them the best-positioned to intervene, diagnose, 
and encourage preventative forms of psychosocial intervention that can 
abate the prevalence of schizophrenia (González &Colarossi, 2014; Lukens 
& Devylder, 2014). Clinical social workers must be aware of the etiology of 
schizophrenia and be prepared to provide relevant coping mechanisms in 
accordance with this understanding.



33 | COLUMBIA SOCIAL WORK REVIEW, VOL. 18 

CONCLUSION
The present article proposes that Black Americans’ disproportionate rate 

of schizophrenia diagnoses may be best understood through the diathesis-
stress model. Under this framework, racism causes psychosocial stress 
that increases the risk of developing adverse health outcomes, including 
schizophrenia. Two hormones, glucocorticoids and adrenocorticotropic 
hormones, have been specifically identified for their association with both 
the stress of racism and the symptoms of schizophrenia. The article calls 
for researchers to further explore this causal pathway through empirical 
study. A series of adaptive coping mechanisms are also recommended for 
immediate use by social workers who wish to address the stress of racism 
among their clients. 

 
ABOUT THE AUTHOR 

 

KASHONDA L. DAVIS earned an MPH and MSSW in Advanced 
Clinical Practice from Columbia University in 2017. Her graduate 
education in clinical practice was fostered by a practicum at Rikers Island 
Correctional Facility where she learned the application of Dialectical 
Behavioral Therapy (DBT) and developed a research interest in the causal 
relationship between stress and mental health outcomes. Upon graduating 
from Columbia University, Kashonda was awarded a behavioral health 
fellowship with Harvard Vanguard Medical Associates in Boston, MA 
where she further honed her skills in evidenced based therapeutic practices. 
Today, Kashonda practices DBT at Kaiser Permanente Department of 
Psychiatry and leads a research study for the Center of Behavioral Health 
and Integration Research at Stanford University. Her clinical interests are 
vested in cultural adaptations of evidenced based care modalities that aid 
in ameliorating health disparities among minority populations.

 
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