Context matters: The impact of neighborhood crime and paranoid symptoms on psychosis risk assessment

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Abstract

Psychosis risk assessment measures probe for paranoid thinking, persecutory ideas of reference, and suspiciousness as part of a psychosis risk construct. However, in some cases, these symptoms may reflect a normative, realistic, and even adaptive response to environmental stressors rather than psychopathology. Neighborhood characteristics, dangerousness for instance, are linked to levels of fear and suspiciousness that can be theoretically unrelated to psychosis. Despite this potential confound, psychosis-risk assessments do not explicitly evaluate neighborhood factors that might (adaptively) increase suspiciousness. In such cases, interviewers run the risk of misinterpreting adaptive suspiciousness as a psychosis-risk symptom. Ultimately, the degree to which neighborhood factors contribute to psychosis-risk assessment remains unclear. The current study examined the relation between neighborhood crime and suspiciousness as measured by the SIPS among predominantly African American help-seeking adolescents (N = 57) living in various neighborhoods in Baltimore City. Uniform Crime Reports, including violent and property crime for Baltimore City, were used to calculate a proxy of neighborhood crime. This crime index correlated with SIPS suspiciousness (r(55) = .32, p = .02). Multiple regression analyses demonstrated that increased neighborhood crime significantly predicted suspiciousness over and above the influence of the other SIPS positive symptoms in predicting suspiciousness. Findings suggest that neighborhood crime may in some cases account for suspiciousness ascertained as part of a psychosis risk assessment, and therefore sensitivity to contextual factors is important when evaluating risk for psychosis.

Introduction

Developing a better understanding of determinants and predictors of risk for psychosis holds numerous advantages towards early identification, and ultimately, intervention. Most research in this area has focused on individual-level risk factors including genetic risk, premorbid functioning, substance use, and subthreshold psychotic symptoms (Ayalew et al., 2012, Cannon et al., 2008, Kirkbride et al., 2009, Tarbox et al., 2013). Examination of broader community and neighborhood factors have helped elucidate socio-economic factors that may increase an individual's risk for developing a psychotic disorder, including exposure to crime, lack of educational opportunities, income inequality, and neighborhood deprivation (Bhavsar et al., 2014, Boydell et al., 2004, Burns et al., 2014, Lasalvia et al., 2014, van Os et al., 2010, Zammit et al., 2010). Stress-vulnerability models have been proposed to help understand the link between chronic exposure to stressors like poverty, crime, or physical environment and social cognitive abilities, and greater risk for psychological and physical health problems (Braveman et al., 2011, Corcoran et al., 2003, Evans, 2004, McLoyd et al., 2009, Nuechterlein and Dawson, 1984, Walker and Diforio, 1997). In a related vein of research, study findings within criminal justice settings observe a higher risk of mental health diagnoses relative to the general population (Flynn et al., 2012, Jarrett et al., 2012, Jarrett et al., 2015). Among many other factors, these incarcerated individuals often have experienced multiple social disadvantages that may in part play a role in the higher rates of psychiatric severity (e.g., impeding access to appropriate care leading to increased severity of symptoms (Flynn et al., 2012, Freedman and Woods, 2013).

These findings underscore the importance of broadening theoretical models of psychosis beyond individual factors, and to consider the context where an individual lives and interacts with the world (Zammit et al., 2010).

Exposure to neighborhood disorder or crime may be significantly associated with the risk for developing a psychotic disorder. Recent findings by Veling et al. (2015) and Kirkbride et al. (2014) reported that neighborhood composition and relative social disadvantage increase the incidence of psychosis, even after controlling for individual factors. At the same time, however, living in a neighborhood with a high rate of crime may also result in increased, but normative, responses of fear or paranoia. High crime neighborhoods and perceived fear of crime have been associated with greater mental health concerns for residents (Curry et al., 2008, Polling et al., 2014). These concerns may reflect a reasonable and potentially ‘adaptive’ response to environmental stressors that impinges on one's sense of safety and well-being, resulting in behavioral changes like increased suspiciousness or social withdrawal (Pearson and Breetzke, 2014, Stafford et al., 2007). An individual's response to threats in the social environment may result in a continuum of suspiciousness that spans normative responses to direct/indirect lived experiences, up to severe paranoia that is delusional and inconsistent with reality (Whaley, 2001). Additionally, prior research indicates that fear or paranoia may be differentially expressed due to differences in race, gender, and previous traumatic experiences (Bentall et al., 2012, Cohen et al., 2004, Harper, 2011, Whaley, 2002). If mental health assessments are conducted without contextual consideration, healthy suspiciousness may be misinterpreted as psychotic (Brown, 2008), leading to overdiagnosis of psychosis among individuals from communities high in crime and other features of social adversity (Barnes, 2008, Brown, 2008, Carson et al., 2014, Pavkov et al., 1989, Strakowski et al., 1996).

Supporting the importance of considering the broader context for individuals, Oher et al. (2014) found that patients in their first episode of psychosis who lived in more urban neighborhoods reported increased hallucinations, reality distortion, and level of depression. Similarly, Ellett et al. (2008) reported that adults with psychosis who were taken to an urban setting as part of a research study showed significantly higher levels of anxiety, paranoia, and negative views compared to a control group of people with psychosis who received a mindfulness activity instead of exposure to an urban setting. The authors suggest that exposure to urbanicity may exacerbate symptom severity. Further, brief urban exposure increased levels of paranoia, anxiety, and negative beliefs about self and others among individuals endorsing persecutory delusions when compared to a neutral indoor activity (Freeman et al., 2015). Although the direction of effects is unknown, there appears to be a consistent association between urbanicity and psychotic symptoms among people in their first episode of psychosis.

Less is known about the impact of neighborhood stressors on subclinical symptoms of psychosis, such as suspiciousness or paranoid thoughts. In a randomly selected community control study of British individuals in the AESOP study, Morgan et al. (2009) reported that suspiciousness was the most commonly self-reported psychotic-like experience (PLE; 12%). Greater PLEs were reported for those who had experienced a greater level of social disadvantage over their lifetime, including separation or death of a parent before adolescence, education, employment, living arrangements and the presence or absence of intimate and social relationships.

To our knowledge, however, no prior studies have examined the impact of neighborhood stressors on attenuated symptoms of psychosis. In psychosis risk assessment, the Structured Interview for Psychosis-risk Syndromes (SIPS; Miller et al., 2003) poses questions probing suspiciousness/persecutory symptoms (see Table 1) to assess paranoid ideas of reference, paranoid thinking, and suspiciousness (McGlashan et al., 2010). Given that risk assessments probe subthreshold levels of symptoms, this question appears particularly relevant for clinicians and researchers working in the clinical high-risk field. When using an instrument like the SIPS, it is not clear how sociocultural factors, like neighborhood crime, may influence an individual's report of suspiciousness. Without an accurate contextual understanding for suspicious or paranoid symptoms, false positive diagnoses may be more likely to occur, confounding the ability to effectively parse true from false positive evaluations of risk, a considerable problem in this field (Fusar-Poli et al., 2013). Fig. 1 illustrates the theoretical contribution of each positive symptom domain used to determine psychosis risk with the SIPS. If reported paranoia or suspiciousness is significantly predicted by neighborhood crime, it is possible this particular domain of the SIPS may be measuring additional constructs that reflect an adaptive response to the environment rather than psychosis- risk.

The aims of the current study were 1) to examine the possible relation between neighborhood crime and clinician-assessed suspiciousness among treatment-seeking adolescents and young adults, and 2) to determine the relative contribution of neighborhood crime on suspiciousness controlling for other SIPS determined psychosis risk relevant variables as measured by the SIPS.

Section snippets

Participants

Participants for the study were recruited through advertisements and referrals from community clinics, and a psychiatric inpatient treatment unit as part of the Youth FIRST/Strive for Wellness program at the University of Maryland, Baltimore County and the University of Maryland School of Medicine, Division of Child and Adolescent Psychiatry. Participants (N = 57) were considered eligible for the study if they were Baltimore City residents, aged 12–22 years, and currently receiving mental health

Results

No data were missing for crime or clinician-rated SIPS data. A small percentage of participants selected not to endorse race (3.5%) or ethnicity (10.5%). In analyses, missing data were handled by excluding cases by variable/analysis. Participants with missing data did not significantly differ across variables of interest compared to participants where variable data was complete (p = .28–.78). Variable skew and kurtosis were within acceptable limits for parametric analyses (see Table 3) (Curran et

Discussion

Results of the current study indicate that neighborhood crime predicts interview derived, participant-reported levels of suspiciousness, above and beyond the effects of other psychosis risk variables. That is to say that reported symptoms of suspiciousness are influenced by neighborhood factors even when accounting for the role of other psychosis-risk factors measured on the SIPS (P1, P3–P5). These findings highlight the importance of contextualizing reported symptoms into an individual's

Contributors

Ms. Wilson oversaw study design, data analysis, interpretation, and manuscript preparation. Dr. Smith assisted with conceptualization, literature review and manuscript preparation. Dr. Kline, Ms. Thompson, Dr. DeVylder, and Ms. Demro contributed to data collection, data analysis, and/or manuscript preparation. Dr. Pitts assisted with statistical analysis. Ms. Bussell oversaw the protocol implementation and contributed to study design. Drs. Schiffman and Reeves contributed to and oversaw all

Role of funding

This work was supported in part by the funding from the Maryland Department of Health and Mental Hygiene, Behavioral Health Administration through the Center for Excellence on Early Intervention for Serious Mental Illness (OPASS# 14-13717G/M00B4400241) and a travel grant awarded by the American Psychological Association Commission on Ethnic Minority Recruitment, Retention and Training in Psychology II (CEMRRAT2) Task Force.

Conflict of interest

All contributors to this manuscript have read and approved the submission to Schizophrenia Research. There are no conflicts of interest or commercial relationships to declare. This paper has not been published or submitted for publication elsewhere. Data for this project was presented as a poster at the Society for Research in Psychopathology annual meeting in October 2015.

Acknowledgments

Special thanks to the families who participated in the research study, and to the Youth First undergraduate research team for their dedication in data collection and entry.

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