Cases That Test Your Skills

Psychosis or ‘cultural paranoia?’

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Mr. A and Mr. B are treated for depression with psychotic features after exhibiting apparent delusional behaviors. Their cases illustrate how ethnic and racial misperceptions can complicate diagnosis.



Culture-related anxiety and paranoia can be difficult to treat because they are reinforced by socially normative practices and beliefs.1 As in the two cases described below, psychiatric patients with deep underlying mistrust may view a therapist from another culture—even though well-meaning—as a racist oppressor.

The clinician’s approach to therapy can help prevent cultural misunderstandings and—most important—misdiagnosis (Box).

MR. A’S CASE: ‘She’s out to get me’

Mr. A, age 38 and African-American, was admitted to the inpatient psychiatry service with neurovegetative depressive symptoms and apparent delusional thinking.

His wife of 20 years, also African-American, was concerned that he was becoming increasingly irrational. She said he accused her of conspiring with his predominantly white supervisors to “bring about my destruction.”

Mr. A consented to admission, acknowledging to the psychiatrist that he had felt depressed and at times considered suicide. He complained that he had recently experienced several unusual “happenings:”

  • Pointing to recent weight loss, Mr. A feared someone was poisoning his food or that he had swallowed a “tracking” device.
  • Mr. A feared that workers who were repairing flood damage in his home were sent to kill him. He remained home during the project, but the fear drove him to a panic attack.
  • After more than 18 years working for the same employer with no notable interpersonal difficulties, Mr. A suddenly could not get along with his coworkers. He accused one colleague of following him to a restaurant.

Mr. A had no previous psychiatric disorder, but some distant relatives had schizophrenia. He was diagnosed as having major depressive disorder, severe with psychotic features; delusional disorder was ruled out. He was prescribed olanzapine, 10 mg at bedtime, and fluoxetine, 20 mg/d.

In the hospital, Mr. A spoke normally with no agitation, increased activity, or evidence of racing thoughts. In group therapy, he explained that he felt “confused.” He also disclosed that a recent extramarital affair left him feeling extremely guilty.


4 tips to help you avoid cultural misunderstandings during therapy
  • Set treatment goals at the start. Make sure you and the patient agree on these goals.
  • Make sure the patient understands he or she can cease treatment at any time. Stress that you are there simply to help achieve the patient’s stated goals.
  • Avoid direct empathic statements during psychotherapy (eg, “You feel angry”); the patient may suspect you are imposing your beliefs. Indirect statements (eg, “It wouldn’t surprise me if you felt angry”) convey curiosity about the patient’s reactions and invite further discussion.
  • Admit when you do not understand a culturally specific colloquialism or mannerism, and ask the patient to explain it at the next session. This usually encourages the patient to keep the follow-up appointment.

A few days later, Mr. A’s suicidal and paranoid ideations disappeared. He expressed anger only while discussing his diagnosis with the attending psychiatrist, who is white. The patient feared that being diagnosed with a psychotic illness would hurt his career. He admitted he felt depressed, but insisted that he now realized his paranoid thoughts were irrational.

Mr. A was discharged after 6 days. He remained on fluoxetine, 20 mg/d; olanzapine was discontinued due to excessive sedation.

The patient also entered insight-oriented psychotherapy to address his depression. Mr. A and the therapist, who is white, spent most of the initial sessions discussing their racial differences. At one point, Mr. A complained to the therapist that white physicians were trying to “railroad” him because of his race.

After nine sessions, Mr. A revealed that he felt isolated at an early age, thinking that others “will use what they know about me against me.” He described growing up in a predominantly black community where most of his neighbors felt oppressed by white people. As therapy progressed, Mr. A realized that this experience influenced his attitudes about race, and that his extramarital affair destroyed his sense of self-trust, which may have fueled his mistrust of others.

After 20 sessions, his marriage and work relationships were stable and his overall mood was much improved. His Outcome Questionnaire 45.2 score decreased across 12 months from 88 (moderate to severe distress) to 55 (level of distress similar to that of non-patients). Delusional behavior has not re-emerged, although his comments continue to reflect mistrust of his supervisors and of white people in general.

What would your diagnosis be? What clues would you gather from Mr. A’s pretreatment behavior and from his progress in therapy?

Dr. Benzick’s observations

Mr. A’s diagnosis upon admission reflected the psychiatrist’s belief that he suffered fixed delusions. By definition, however, a delusion is a false belief that is not “ordinarily accepted by other members of the person’s culture or subculture.”2


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