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. Author manuscript; available in PMC: 2018 Oct 24.
Published in final edited form as: Am J Orthopsychiatry. 2017 Aug 17;87(6):636–645. doi: 10.1037/ort0000285

Discrimination and Symptoms of Obsessive-Compulsive Disorder Among African Americans

Monnica T Williams 1, Robert Joseph Taylor 2, Dawne M Mouzon 3, Linda A Oshin 4, Joseph A Himle 5, Linda M Chatters 6
PMCID: PMC6200143  NIHMSID: NIHMS899685  PMID: 28816492

Abstract

This study examined symptoms of obsessive-compulsive disorder (OCD) in a nationally-representative sample of African American adults (n = 3,570), and correlations between OCD symptom dimensions and experiences of discrimination. Two categories of discrimination were examined, everyday racial discrimination and everyday non-racial discrimination (e.g., due to gender, age, and weight) to determine if racial discrimination had a unique impact on OCD symptoms. Results indicated that everyday racial discrimination was related to both categories of obsessions and all four categories of compulsions. Everyday non-racial discrimination, however, was not related to any of the categories of obsessions or compulsions. This indicates that racial discrimination is uniquely related to obsessions and compulsions for African Americans. The implications of these findings are discussed.

Keywords: Obsessive-compulsive disorder, discrimination, African Americans, symptom dimensions, microaggressions

OCD and Symptoms of OCD among African Americans

Obsessive-compulsive disorder (OCD) is a chronic, disabling disorder that is characterized by distressing obsessions and repetitive compulsions. Although the prevalence of OCD in African Americans is similar to the general population (1.6%; Kessler, Berglund, & Demler, 2005; Himle et al., 2008), they are less likely to receive effective care or experience a remission of symptoms (Himle et al., 2008; Turner et al., 2016). OCD in African Americans is associated with psychiatric comorbidities and impairments across many important domains, such as work and home life (Himle et al., 2008; Williams, Brown, & Sawyer, 2017). A better understanding of OCD in African Americans is an important public health goal, thus the purpose of this paper is to investigate the relationships between everyday racial discrimination and everyday non-racial discrimination (i.e., due to gender, age, and weight) and symptoms of OCD in a nationally representative sample of African Americans.

OCD is a heterogeneous disorder with varied symptom presentations. Studies of OCD have generally established four primary obsession/compulsion symptom dimensions: contamination/cleaning, doubts about harm/checking, symmetry/ordering, and unacceptable thoughts/mental rituals (Williams, Mugno, Franklin, & Faber, 2013), although some researchers have found deviations from this pattern (e.g., Katerberg et al., 2010). Only one investigation has studied symptom dimensions in clinically diagnosed African Americans with OCD, and findings were similar to factor analytic studies with primarily White participants (Williams, Elstein, Buckner, Abelson, & Himle, 2012). However, in the African American sample, the unacceptable thoughts/mental rituals dimension included two separate categories, described as aggression/mental rituals (worries about harming others intentionally) and sexuality fears/reassurance (worries about doing something sexually deviant). Furthermore, the principal component analysis revealed unexpected groupings, such that repeating compulsions were included as part of the sexuality fears/reassurance dimension, and counting compulsions were included with the aggression/mental rituals dimension. Finally, African Americans with OCD reported more contamination symptoms and were twice as likely to report excessive concerns with animals compared to similar studies with European and European American samples.

Findings surrounding contamination concerns were congruent with studies that found elevated concerns about cleanliness and higher reports of washing behaviors among African Americans compared to European Americans in non-clinical samples (e.g., Williams, Turkheimer, Schmidt, & Oltmanns, 2005). These differences were determined to be caused by cultural differences in cleaning attitudes and not greater OCD pathology in African Americans overall (Williams & Turkheimer, 2007). Further, the study by Williams, Elstein et al. (2012) demonstrated that African Americans with an OCD diagnosis also have greater contamination concerns. One hypothesis for the increased contamination concerns is that historical stereotypes about African Americans being able to contaminate European Americans by sharing facilities led to increased washing as form of stereotype compensation (Williams, Turkheimer, Magee, & Guterbock, 2008). In support of this, a subsequent study found that priming African Americans with Jim Crow stereotypes increased washing behaviors (Olatunji, Tomarken, & Zhao, 2014).

Discrimination and Mental Health

Discrimination is a psychosocial stressor resulting from unfair treatment based on a status characteristic such as race/ethnicity, gender, and socioeconomic status (Berger & Sarnyai, 2015). The Stress Process Model suggests that discrimination can impact mental health through multiple potential mechanisms such as undermining a sense of personal control (e.g., mastery) or self-esteem (Pearlin, 1989; Turner, 2010). Studies repeatedly show that Blacks experience more stress exposure than Whites, both specifically in terms of higher rates of discrimination (e.g., APA, 2016; Ayalon & Gum, 2011; Kessler, Mickelson, & Williams, 1999; Luo, Granberg, & Wentworth 2012; Sternthal, Slopen, & Williams 2011) and also in terms of stresses associated with finances, the labor market, relationships, crime/violence, and health (APA 2016; Sternthal, Slopen, & Williams 2011).

Discrimination can assume two forms. Major discrimination is typically conceptualized as discrete macro-level events such as being unfairly fired, not hired, harassed by the police, or denied a bank loan (Williams, Yu, Jackson, & Anderson, 1997). Major discrimination can affect mental health not only due to the singular, acute event, but via the health-related impact of subsequent stressors. For example, major discrimination events can harm mental health due not only to the initial insult (e.g., the stress of being unfairly fired) but also via stressors resulting from the event (e.g., family stress and economic deprivation due to job loss), a concept known as stress proliferation (Pearlin, 1999). Everyday discrimination, on the other hand, comprises interpersonal daily hassles and insults (also termed, microaggressions) such as receiving inferior service, being treated with less respect and courtesy, and being unfairly followed in stores (Sue et al., 2007; Williams et al., 1997). Unlike major discrimination, everyday discrimination is an ongoing psychosocial stressor that is chronic nature. It is the very chronicity of everyday discrimination that is emotionally taxing and therefore detrimental to mental health. Indeed, recent studies show that a heightened state of race related vigilance often resulting from chronic discrimination can lead to a state of continued monitoring and anticipation of further discriminatory events, a phenomenon that has been linked to negative health outcomes (Hicken et al. 2013; Hicken, Lee, & Hing 2017).

Despite their conceptual differences, comprehensive reviews of the scientific literature find that both major and everyday discrimination are negatively associated with physical and mental health (Lewis, Cogburn, & Williams, 2015; Mays, Cochran, & Barnes, 2007; Williams & Mohammed, 2013). For example, both major discrimination and everyday discrimination are associated with higher levels of depressive symptoms (Ayalon & Gum, 2011; Banks, Kohn-Wood, & Spencer, 2006; Hudson, Puterman, Bibbins-Domingo, Matthews, & Adler, 2013; Marshall & Rue, 2012) and anxiety symptoms (Banks et al., 2006; Soto, Dawson-Andoh, & BeLue, 2011). Everyday discrimination is also associated with increased psychological distress, regardless of whether individuals attribute this unfair treatment to racial or other (non-racial) characteristics (Chae, Lincoln, & Jackson, 2011).

In addition to these general measures of mental health, everyday discrimination has also been linked to higher risk of various psychiatric disorders. For example, a recent study found that everyday racial discrimination was associated with higher odds of major depression, post-traumatic stress disorder, panic disorder, and substance use disorder among African Americans, Asians, and Hispanics in the Collaborative Psychiatric Epidemiology Study (Chou, Asnaani, & Hofmann, 2012). Another analysis of the combined CPES data (Whites, African Americans, Black Caribbeans, Asians and Hispanics) found that overall everyday racial discrimination was positively associated with panic attacks (Hearld, Budhwani, & Chavez-Yenter, 2015). Research strictly among African Americans also found that everyday discrimination was positively associated with social anxiety disorder (Levine et al., 2014) and having a lifetime anxiety disorder among older African Americans (Mouzon et al., 2017). The relationship between racial discrimination and increased risk of psychiatric symptoms has been attributed to the similarity between one's response to discrimination events and anxiety symptoms (Smith, Allen, & Danley, 2007) and, as noted earlier, this relationship is often described in terms of stress (e.g., Berger & Sarnyai, 2015).

The National Survey of American Life (NSAL) has generated important findings regarding the link between discrimination and mental disorders. For example, data from African American respondents in the NSAL show higher odds of major depressive disorder, generalized anxiety disorder, and substance use disorder among those who experience high levels of everyday discrimination (Clark, Salas-Wright, Vaughn, & Whitfield, 2015). Greater exposure to everyday discrimination is also associated with higher odds of psychotic experiences (Oh, Yang, Anglin, & DeVylder, 2014). Both everyday and major discrimination are associated with higher odds of alcohol and drug use disorders among both African Americans and Caribbean Blacks (Hunte & Barry, 2012). Everyday discrimination – but not major discrimination – has also been linked with social anxiety disorder for African Americans, Caribbean Blacks, and Whites (Levine et al., 2014). Finally, discrimination (both racial and non-racial) is associated with generalized anxiety disorder among African Americans (Soto et al., 2011).

Purpose of this Investigation

Although discrimination has been linked to a number of specific mental health issues, to date no one has examined the relationship between discrimination (racial or non-racial) and OCD symptoms. Although it has been theorized that racial discrimination contributes to OCD severity, which may differ by symptom dimension, no prior investigation has examined this issue (Williams & Jahn, 2017). Greater symptom severity has been correlated to poorer treatment outcomes (Hurley, Saxena, Rauch, Hoehn-Saric, & Taber, 2002), and subsequent increased periods of disability leading to reduced educational attainment and greater disease burden (Himle et al., 2008). Therefore, understanding factors that contribute to OCD-related impairment in African Americans is an important public health concern.

To this end, the current study attempts to determine the association between everyday racial and non-racial discrimination and specific OCD symptoms in a large, nationally representative sample of African American adults. Based on the research connecting the experience of racial stereotyping with increased washing in African Americans (Williams et al., 2008; Olatunji et al., 2014), we hypothesize a correlation between everyday racial discrimination and obsessions surrounding contamination and compulsions that include washing. We have no clear data to predict how discrimination will effect other facets of OCD, other than the likelihood that OCD symptoms will be correlated to everyday discrimination due to overall increased stress.

Methods

Participants

The National Survey of American Life: Coping with Stress in the 21st Century (NSAL) is an epidemiological study implemented by the Program for Research on Black Americans at the Institute for Social Research at the University of Michigan. A total of 6,082 interviews were conducted with individuals aged 18 and over, which included 3,570 African Americans, 891 non-Hispanic Whites, and 1,621 Blacks of Caribbean descent. This study includes only the African American participants. The response rate for African Americans was 70.7%, and more details about the NSAL methodology are available from Jackson et al. (2004). Data collection occurred from February 2001 to June 2003. Respondents were compensated for their participation. The NSAL study was approved by the University of Michigan's Institutional Review Board.

Measures

Dependent Variables

In the NSAL, diagnostic assessment of mental disorders was conducted using the Diagnostic and Statistical Manual (DSM-IV) World Mental Health Composite International Diagnostic Interview [WMH-CIDI] (Kessler & Ustan, 2004), which is a structured diagnostic interview, administered by trained lay interviewers. To assess OCD, the CIDI short-form version Obsessive-Compulsive Disorder diagnostic module (CIDI-SF OCD; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1989) was administered, rather than the full WMH-CIDI OCD module. The CIDI-SF OCD, which assesses the presence of specific sets of obsessions and compulsions, are the dependent variables for this analysis. We specifically assessed two indicators of obsessions: contamination (based on fears about having dirty hands or germs) and unacceptable thoughts (causing harm or other shameful thoughts). Four indicators of compulsions were also assessed: washing and checking (behaviors that included washing hands and checking doors), ordering (arranging things in a certain order), counting, and repeating certain words. We also analyzed the number of compulsions, the number of obsessions, and the odds of meeting criteria for a probable OCD diagnosis. The CIDI-SF OCD questions used in this study are presented in Table 2. All African Americans in the NSAL were asked these questions about obsessions and compulsions.

Table 2. Exact Question Wording for the Indicators of Obsessions and Compulsions.
Obsessions
Contamination I want to ask you next about whether you have ever been bothered by having certain unpleasant thoughts that kept entering your mind against your wishes. An example would be the persistent idea that your hands are dirty or have germs on them. Have you ever had any unpleasant thoughts like that?
Unacceptable Thoughts Another example of an unpleasant thought would be the persistent idea that you might harm someone, even though you really didn't want to. Or you might have had thought you were ashamed of, but couldn't keep them out of your mind. Have you ever had any unpleasant and persistent thought like that?
Compulsions
Washing & Checking Some people have the unpleasant feeling that they have to do something over and over again even though they know it is really foolish, but they can't resist doing it – things like washing their hands again and again or going back several times to be sure they've locked a door or turned off the stove. Have you ever had to do something like that over and over?
Arranging Was there ever a time when you felt you had to do something in a certain order, like putting your clothes on in a certain way, and had to start all over again if you did it in the wrong order?
Counting Has there ever been a period of time of several weeks when you felt you had to count something, like the squares in a tile floor, and couldn't resist doing it even when you tried to?
Repeat Words Did you ever have a period of time when you had to say certain words over and over, either aloud or to yourself?
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Independent Variables

The main independent variable is everyday discrimination, which was designed to assess interpersonal forms of routine experiences of discrimination (Williams et al., 1997). There were two measures of everyday discrimination used for this analysis: everyday racial discrimination and everyday non-racial discrimination. In order to create these two measures respondents were first asked 10 items which measure the frequency of overall everyday discrimination. These items were: treated with less courtesy; treated with less respect; received poor restaurant service; perceived as not smart; perceived as dishonest; perceived as not as good as others; being feared; being insulted; being threatened; and followed in stores. Response values for each item included: 5 (almost every day), 4 (at least once a week), 3 (a few times a month), 2 (a few times a year), 1 (less than once a year), and 0 (never). The responses to these 10 items were summed with higher scores indicating more discrimination. Participants who reported experiencing any discrimination were asked to identify the primary reason for such experiences (e.g., race, gender, sexual orientation, income, age, height, weight). Based on this item, two everyday discrimination variables were created: 1) discrimination that was attributed to race, and 2) discrimination that was attributed to nonracial reasons such as age or weight. These are the two main independent variables in this analysis. These measures of everyday discrimination have been well established in the health and mental health literature. Numerous studies use these measures and analyses in various populations including African Americans, Latinos, Asians and non-Hispanic whites (see reviews by Lewis, Cogburn, & Williams, 2015, and Williams & Mohammed, 2013).

Several demographic and health variables were included as controls. Demographic variables used included age, gender, marital status (married, unmarried), education, family income, work status, material hardship, self-rated physical health, self-rated oral health and self-rated mental health. Missing data for family income and education were imputed using an iterative regression-based multiple imputation approach incorporating information about age, gender, region, race, employment status, marital status, home ownership, and nativity of household residents. Age was measured in years and collapsed into 3 categories (18-34, 35-54, 55 and older). Work status has 3 categories [employed, unemployed, and not in labor force (i.e., retired, disability, students)]. Educational attainment was measured in number of years and collapsed into 4 categories (11 years and less, 12, 13-15, 16 and more years). Marital status has two categories (married and cohabiting, not married). Family income has four categories (less than $15,000, $15,000-$27,999, $28,000- $46,999 and $47,000 and more).

Material hardship is a summary score comprised of 7 items assessing whether or not respondents could meet basic expenses, pay full rent or mortgage, pay full utilities, had utilities disconnected, had telephone disconnected, were evicted for non-payment, or could not afford leisure activities in the past 12 months. A higher score on this item indicates higher levels of economic hardship (Cronbach's α =.76).

Three subjective health items were used representing self-rated physical health, self-rated oral health, and self-rated mental health. The measure for self-rated physical health asked: How would you rate your overall physical health at the present time? Self-rated oral health was assessed by: How would you rate the overall condition of your teeth, gums, and mouth at the present time? Finally, self-rated mental health asked: How would you rate your overall mental health at the present time? All three self-rated health measures used response categories ranging from poor (1), fair, good, very good, to excellent (5). The distribution of the study variables is presented in Table 2.

Data Analytic Strategy

SAS 9.13 was used to analyze the distribution of basic demographic characteristics and to execute the multivariate analysis. Logistic regression analysis was performed for the analysis of the six dichotomous symptom variables and the likelihood of having OCD. Logistic regression is the appropriate multivariate analysis procedure to use for dichotomous dependent variables (e.g., whether or not a person has ever had a contamination obsession) with continuous and categorical independent variables (Hosmer, Lemeshow, & Sturdivant, 2013). Odds ratio estimates and 95% confidence intervals are provided for the logistic regression analysis.

There are two count variables in our analysis, the number of obsessions and the number of compulsions. An examination of the univariate distribution for these dependent variables indicated that they were not normally distributed. In particular, the variance exceeded the mean which indicated overdispersion. Consequently, instead of linear regression we used negative binomial regression, which is the appropriate technique for this type of nonnormal distribution (Hilbe, 2011). For the negative binomial regressions, incidence rate ratio estimates and 95% confidence intervals are presented. For both the logistic regression and negative binomial regression analysis statistical significance determined using the design-corrected F-statistic. To obtain results that are generalizable to the African American population all statistical analyses accounted for the complex, multistage, clustered design of the NSAL sample, unequal probabilities of selection, nonresponse, and post-stratification to calculate weighted, nationally representative population estimates and standard errors.

Results

The demographic profile of the sample (Table 1) indicates that 56% of respondents are women and a third are between the ages of 18 to 34, roughly 40% are 35-45 years, and 20% are 55 years of age and older. Forty-two percent of respondents are married or cohabiting with a partner, while 58% are not married. By-and-large, respondents are employed (67%), while 10% are unemployed and 23% are not in the labor force. With respect to education, 24% have 11 years of education or less, 38% have at least 12 years of education, 24% have between 13-15 years, and 14% have 16 or more years of education. Information on household income indicates that percentages are roughly comparable across income levels –25% of the sample have household incomes less than $15,000, 24% report incomes of $15,000-27,999, 25% have incomes of $28,000-$46,999, and 26% report incomes of $47,000 or more. The mean level of reported material hardship for the sample is .89. Information on self-reported health (on a scale of 1-5, with 5 being excellent) indicates that the average physical health self-rating is 3.42, oral health is 3.11, and mental health is 3.84. Finally, respondents were more likely to attribute the discrimination that they encountered to race as opposed to other non-racial reasons.

Table 1. Demographic Characteristics of the Sample and Distribution of Study Variables.

% (S.E.) Mean (S.D.) N
OBSESSIONS
Contamination 7.90 (0.82) 3406
Unacceptable Thoughts 8.29 (0.62) 3407
# of Symptoms of Obsessions 0.16 (0.40) 3409
COMPULSIONS
Washing and Checking 10.63 (0.70) 3407
Arranging 5.19 (0.52) 3408
Counting 3.53 (0.39) 3409
Repeating Words 6.85 (0.45) 3408
# of Symptoms of Compulsions 0.26 (0.62) 3410
OBSESSIVE COMPULSIVE DISORDER 1.60 (0.26) 3417
Everyday Racial Discrimination 8.45 (8.85) 3412
Everyday Non-Racial Discrimination 3.21 (6.36) 3411
Age
 18-34 35.73 (1.40) 1232
 35-54 42.65 (0.87) 1501
 55 and older 21.62 (1.06) 837
Gender
 Male 44.03 (0.83) 1271
 Female 55.97 (0.83) 2299
Work Status
 Employed 66.83 (1.05) 2334
 Unemployed 10.07 (0.71) 366
 Not in Labor Force 23.10 (0.96) 861
Education
11 years and less 24.19 (1.20) 920
12 years 37.86 (1.09) 1362
13-15 years 23.83 (0.97) 809
16 and more years 14.12 (1.13) 479
Marital and Romantic Status
 Married and Cohabitating 41.65 (1.03) 1220
 Not Married 58.35 (1.03) 2333
Household Income
Less than $15,000 24.70 (1.28) 1054
$15,000- $27,999 23.76 (0.97) 925
$28,000- $46,999 25.50 (1.04) 866
$47,000 and more 26.05 (1.67) 725
Material Hardship 0.89 (1.31) 3528
Self-Rated Physical Health 3.42 (0.95) 3437
Self-Rated Oral Health 3.11 (0.99) 3435
Self-Rated Mental Health 3.84 (0.91) 3436
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Frequencies are unweighted; Percents and means are weighted to be nationally representative of the given population and subpopulations in the U.S.

Only 1.6% of African Americans met criteria for a probable OCD diagnosis (see Himle et al., 2008 for a more thorough examination of the correlates of OCD among African Americans). Roughly eight percent of respondents had contamination (7.9%) and unacceptable thoughts (8.29%) obsessions. The percent of African Americans with compulsions ranged from 10.63% with washing and checking compulsions to 3.53% with checking compulsions.

Table 3 presents the analysis of discrimination and OCD obsessions. Everyday racial discrimination was positively associated with both types of obsessions assessed. That is, African Americans who reported higher levels of discrimination were more likely to report that they had contamination obsessions and unacceptable thoughts obsessions. However, discrimination that was attributed to other non-racial attributes (e.g., weight, age) was not significantly associated with either contamination or unacceptable thoughts obsessions.

Table 3. Weighted Logistic Regression Analysis of Everyday Racial Discrimination and Everyday Non-Racial Discrimination on OCD Obsessions among African Americans1.

Contamination Unacceptable Thoughts
OR (95% C.I.) OR (95% C.I.)
Everyday Racial Discrimination 1.04 (1.02, 1.06) 1.04 (1.02, 1.05)
p <0.0001 <0.0001
F 5.04 11.01
Prob > F 0.0007 <0.0001
N 3273 3274
Everyday 1.01 (0.99, 1.03) 1.01 (0.99, 1.03)
Non-Racial
Discrimination
p 0.18 0.40
F 3.56 7.22
Prob > F 0.005 0.0001
N 3272 3273
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Note: OR= Odds Ratio, C.I.=Confidence Intervals

1

Age, gender, income, employment status, education, marital status, material hardship, self-rated physical health, self-rated oral health and self-rated mental health were controlled for in the final models.

*

p<.05

**

p< .01

***

p<.001

The analysis of OCD compulsions and everyday discrimination is presented in Table 4. These findings are similar to the findings for discrimination and obsessions. Everyday racial discrimination was positively associated with all 4 compulsions. African Americans who indicated that they had experienced higher levels of racial discrimination were more likely to report that they had washing and checking, arranging, counting, and repeating compulsions. Non-racial discrimination, however, was not significantly associated with any of the 4 types of OCD compulsions.

Table 4. Weighted Logistic Regression Analysis of Everyday Racial Discrimination and Everyday Non-Racial Discrimination on OCD Compulsions among African Americans1.

Washing and Checking Arranging Counting Repeating Words
OR (95% C.I.) OR (95% C.I.) OR (95% C.I.) OR (95% C.I.)
Everyday 1.03 (1.02, 1.05) 1.05 (1.03, 1.07) 1.06 (1.04, 1.08) 1.05 (1.03, 1.06)
Racial
Discrimination
p <0.0001 <0.0001 <0.0001 <0.0001
F 6.45 11.69 7.20 15.55
Prob > F 0.0001 <0.0001 0.0001 <0.0001
N 3274 3275 3277 3276
Everyday 1.00 (0.99, 1.02) 0.99 (0.97, 1.01) 1.00 (0.97, 1.03) 1.00 (0.99, 1.02)
Non-Racial
Discrimination
p 0.53 0.37 0.97 0.66
F 4.92 5.43 6.25 12.46
Prob > F 0.0008 0.0004 0.0002 <0.0001
N 3273 3274 3276 3275
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Note: OR= Odds Ratio, C.I.=Confidence Intervals

1

Age, gender, income, employment status, education, marital status, material hardship, self-rated physical health, self-rated oral health and self-rated mental health were controlled for in the final models.

*

p<.05

**

p< .01

***

p<.001

Table 5 presents the analysis of everyday discrimination and the number of obsessions, the number of compulsions, and meeting diagnostic criteria for OCD. The findings of this analysis are consistent with the results presented in Tables 3 and 4. Everyday racial discrimination was positively associated with all three dependent variables, whereas, non-racial discrimination was not significantly associated with any of the three dependent variables. African Americans who indicated that they had experienced higher levels of racial discrimination had a greater number of obsessions, a greater number of compulsions, and had an increased risk of meeting criteria for OCD.

Table 5. Weighted Analysis of Everyday Racial Discrimination and Everyday Non-Racial Discrimination on number of OCD Obsessions, number of OCD compulsions and OCD disorder among African Americans1.

Number of Symptoms of Obsessions2 Number of Symptoms of Compulsions2 Obsessive Compulsive Disorder3
IRR (95% C.I.) IRR (95% C.I.) OR (95% C.I.)
Everyday 1.03 (1.02, 1.05) 1.04 (1.03, 1.05) 1.05 (1.01, 1.09)
Racial
Discrimination
p <0.0001 <0.0001 0.02
F 16.95 22.64 10.92
Prob > F <0.0001 <0.0001 <0.0001
N 3276 3277 3280
Everyday 1.01 (0.99, 1.02) 1.00 (0.99, 1.01) 1.01 (0.97, 1.05)
Non-Racial
Discrimination
p 0.22 0.95 0.51
F 8.51 9.37 13.11
Prob > F <0.0001 <0.0001 <0.0001
N 3275 3276 3279
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Note: IRR= Incidence Rate Ratio, OR= Odds Ratio, C.I.=Confidence Intervals

1

Age, gender, income, employment status, education, marital status, material hardship, self-rated physical health, self-rated oral health and self-rated mental health were controlled for in the final models.

2

Negative Binomial Analysis is used for the number of symptoms of obsessions and the number of symptoms of compulsions

3

Logistic Regression is used for the analysis of obsessive compulsive disorder.

*

p<.05

**

p< .01

***

p<.001

Discussion

OCD Symptoms and Discrimination

While previous research consistently links discrimination to negative mental health outcomes such as depression and general anxiety symptoms (Schmitt, Branscombe, Postmes, & Garcia, 2014), no study to date has investigated the relationship between discrimination and OCD symptoms. Significant relationships were found between everyday racial discrimination and both contamination and unacceptable thought obsessions, as well as all four compulsions (washing and checking, arranging, counting, and repeating words). Everyday racial discrimination was also significantly related to the number of obsessions, the number of compulsions, and OCD criteria. In contrast, no significant relationships were found between non-racial everyday discrimination (e.g. discrimination due to gender, sexual orientation, weight, etc.) and any of the dependent variables.

These results suggest that daily experiences with discrimination due to one's African American identity – as opposed to other status characteristics (e.g., age, weight) - are uniquely related to the expression of obsessions and compulsions. Previous research found that general discrimination affected symptoms of Generalized Anxiety Disorder (GAD) among African Americans, Caribbean Blacks, and non-Hispanic whites, but race-based discrimination was a predictor of GAD symptoms among African Americans only (Soto et al., 2011). Similarly, other work indicates that everyday racial discrimination – but not everyday non-racial discrimination – is associated with higher odds of chronic health conditions (Mouzon, Taylor, Woodward, & Chatters, 2016). Everyday racial discrimination is also more strongly tied to serious psychological distress among African Americans than everyday non-racial discrimination (Chae, Lincoln, & Jackson, 2011). Taken together, these findings are consistent with social science research suggesting that characteristics that are central to one's personal identity are the most vulnerable to environmental insults (Thoits, 2013). In other words, the salient nature of one's racial identification likely accounts for the stronger impact of everyday racial discrimination than everyday non-racial discrimination on OCD disorder and symptoms.

Previous research findings connecting racial discrimination and anxiety symptoms suggest that this may be due to racial battle fatigue (Himle, Baser, Taylor, Campbell, & Jackson, 2009; Levine et al., 2014; Soto et al., 2011). Racial battle fatigue, a common social-physiological stress response to everyday racial discrimination, or racial microaggressions, includes responses such as elevated heart beat and hypervigilance (Smith et al., 2007). While racial battle fatigue overlaps with the symptoms for GAD and Social Anxiety Disorder (SAD), it does not overlap with the symptoms of OCD. The present results suggest that racial battle fatigue may also be predictive of OCD symptoms; future research should explicitly explore this possibility.

Others have suggested that the psychological resources that are required to manage everyday experiences with discrimination deplete resources to manage other everyday stressors, which may contribute to worse mental health (Soto et al., 2011). Consistent with the Stress Process Model (Pearlin 1989), it is likely that increased everyday racial discrimination depletes resources that African Americans need in order to manage their obsessions and/or compulsions resulting in increased symptoms of OCD. If racism causes or exacerbates OCD symptoms, this could be one explanation for higher scores on OCD cognitions in ethnic minority students (Wheaton et al., 2013). Furthermore, racism-related vigilance can chronically activate the stress response and has been linked to increased threat emotion (Sawyer et al. 2012). Another recent study found that vigilance mediated the relationship between discrimination and stress among Blacks, indicating that vigilance is an important pathway by which discrimination creates stress and subsequently increases depressive symptoms (Himmelstein et al., 2015). Given that most vigilance research focuses on physical health, future research should investigate mental health outcomes related to this process, as well as the causal mechanisms through which discrimination affects mental health, and OCD specifically.

Although this study found that everyday racial discrimination was related to increased obsessions and compulsions regardless of symptom type, previous studies have suggested that concern about discrimination and stereotypes that are prevalent for African Americans can contribute to increases in specific OCD symptom dimensions. Williams, Elstein, et al. (2012), found that relative to non-Hispanic Whites, African Americans had twice the prevalence of obsessions of being misunderstood, which suggests that the stereotypes that African Americans frequently encounter about being unintelligent may specifically influence OCD obsessions. In terms of checking, African Americans may feel an increased need to ensure that things have been done properly to counteract fears of being unfairly accused of negligence, which may have high social consequences for stigmatized minorities who combat stereotypes surrounding laziness. Additionally, as previously noted, the increased prevalence of contamination obsessions among African Americans may be a reaction to historical associations of African Americans with dirtiness (Williams & Turkheimer, 2007).

Finally, it is possible that the relationship between discrimination and obsessions and compulsions may be exacerbated due to lack of treatment of OCD symptoms. African Americans tend to under-utilize mental health services (Ayalon & Alvidrez, 2007) and African Americans with OCD are significantly more likely that non-Hispanic Whites with OCD to endorse concern about discrimination from a mental health provider as a barrier to receiving treatment (Williams, Domanico, Marques, Leblanc, & Turkheimer, 2012). African Americans adults are less likely to seek help than Whites, and this difference is explained in part by the experience of everyday discrimination (Woodward, 2011; Woodward, Chatters, Taylor, Neighbors, & Jackson, 2010). Thus, it is possible that African Americans who encounter more everyday racial discrimination are more likely to avoid treatment for their OCD symptoms, thereby causing them to worsen.

Limitations

As with any study, this investigation had several limitations. First, given the cross-sectional design of the study, we cannot make claims of causality. Previous studies examining the impact of discrimination on mental health using longitudinal data have indicated that increased discrimination predicts worse mental health at a later time-point, suggesting that discrimination contributes to worse mental health (Hoggard, Byrd, & Sellers, 2015). This has not been investigated in OCD symptoms, so it is possible that an increase in OCD symptoms may predict increased everyday discrimination. This seems unlikely, but could be possible if African Americans with socially unacceptable obsessions or compulsions misattribute others' reactions to their obsessions or compulsions as race-based discrimination.

Secondly, while the current study investigated sex-based and other sources of discrimination as an alternative to race-based discrimination, intersectional theorists have suggested that one cannot simply consider discrimination based on race and sex separately because experiences of race-based discrimination are qualitatively different for African American men and women (Else-Quest & Hyde, 2016; Smith et al., 2007; Thomas, Witherspoon, & Speight, 2008). This suggests that African Americans may find it difficult to attribute experiences of discrimination to race or sex alone. One of the limitations of the everyday discrimination measure is that as a global measure, individuals are asked to identify the primary reason that they experienced discrimination. As such, the measure does not allow individuals to provide multiple possible reasons as to why they were discriminated against. Consequently, the measure cannot assess whether individuals are aware of and/or endorse intersectional explanations for their experience of discrimination.

Finally, accurate assessment of OCD is demanding due to the heterogeneity of symptoms, and not all possible OCD symptoms were included in the CIDI-SF OCD. For African Americans, measurement of OCD symptoms has been particularly challenging due to higher scores on contamination subscales (Williams, Wetterneck, & Sawyer, 2015). This specific problem has only been seen in self-report measures. However, one structured interview tool demonstrated a high miss rate when assessing African Americans for OCD, even when administered by primarily Black clinicians with special training (Williams, Debreaux, & Jahn, 2016). So, the assessment techniques used in this investigation may not capture all African Americans with OCD symptoms.

Implications

While there is no significant difference in the prevalence of OCD in African Americans compared to the general population (Himle et al., 2008), it is important to investigate factors unique to this population that may affect severity of symptoms. Racial discrimination appears to contribute to the severity of all types of obsessions and compulsions, even among persons who may not meet criteria for a formal diagnosis. Previous research suggests that differences in cognitive appraisal of discrimination experiences may change its impact on negative mental health outcomes (King, 2005). Therapists treating OCD symptoms in African Americans should discuss how their clients are appraising and managing experiences of racial discrimination. Additionally, clients should be encouraged to persist in their help seeking efforts, despite the barriers to treatment posed by concerns about everyday racial discrimination.

The problem, however, will not be solved simply by addressing client cognitions or behaviors. If, in fact, racism in a contributing factor to OCD symptomology, then we must also consider how we can utilize psychological principles to diagnose and repair America's social psychopathology to facilitate wellness in people of color everywhere.

Public Policy Relevance.

African Americans demonstrate increased obsessions and compulsions in relation to racial everyday discrimination, but not in relation to non-racial everyday discrimination. These findings suggest that policy makers should consider the unique negative impact of racial discrimination on the mental health of African Americans, in addition to other forms of discrimination that they may face.

Acknowledgments

Funding: The data collection for this study was supported by the National Institute of Mental Health (NIMH; U01-MH57716), with supplemental support from the Office of Behavioral and Social Science Research at the National Institutes of Health (NIH) and the University of Michigan. The preparation of this article was supported by grants from the National Institute on Aging to RJT and DMM (P30AG015281) and from the National Institute of General Medicine Sciences to LMC (NIGMS R25GM058641).

Contributor Information

Monnica T. Williams, College of Liberal Arts & Sciences, Department of Psychological Sciences, School of Medicine, Department of Psychiatry, University of Connecticut

Robert Joseph Taylor, School of Social Work, Program for Research on Black Americans, Institute for Social Research, University of Michigan, Ann Arbor.

Dawne M. Mouzon, Edward J. Bloustein School of Planning and Public Policy, Institute for Health, Health Care Policy, and Aging Research, Rutgers University

Linda A. Oshin, College of Liberal Arts & Sciences, Department of Psychological Sciences, University of Connecticut

Joseph A. Himle, School of Social Work, Department of Psychiatry, University of Michigan, Ann Arbor

Linda M. Chatters, School of Social Work, School of Public Health, Program for Research on Black Americans, Institute for Social Research, University of Michigan, Ann Arbor

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