Racial and Ethnic Diagnostic Patterns in Schizophrenia Spectrum Disorders

  • Kayla Gurak
  • Jessica Maura
  • Amy Weisman de Mamani
  • Ana Martinez de Andino
  • Irwin Rosenfarb


The literature on racial and ethnic diagnostic patterns (as these pertain to schizophrenia spectrum disorders) is reviewed in this chapter. The chapter begins with a review of the literature on the diagnostic patterns among racial and ethnic minorities in the USA and abroad, followed by a review of racial/ethnic differences in symptom severity, symptom expression, and prevalence rates. This is then followed by a review of the empirical literature that offers explanations about why differential diagnostic patterns are observed. This review explores the question of whether differential patterns are due to inherent differences between racial/ethnic groups or if clinician biases and/or decision-making processes are contributing to differential diagnostic practices. Finally, literature that points to cultural mistrust, paranoia, and other environmental factors (e.g., stress) as potential variables that may contribute to the differential diagnostic patterns among racial/ethnic groups is reviewed. These reviews suggest that Black patients are three to four times more likely to receive a schizophrenia spectrum diagnosis. Findings also suggest that racial/ethnic variations may exist on a symptom level, with greater differences observed among positive symptom profiles. This review suggests that unawareness of cultural differences in symptom expression, cultural mistrust, and environmental factors (e.g., low SES) may be related to greater likelihood of receiving a schizophrenia spectrum diagnosis but do not fully account for the diagnostic discrepancies observed among racial/ethnic groups. To better understand these relationships, we conclude with recommendations to improve diagnostic accuracy and cultural competence (e.g., greater reliance on the Cultural Formulation Interview) and suggestions for future research that may further clarify the racial/ethnic diagnostic conundrum (e.g., using analog research studies).


Schizophrenia Clinical diagnosis Racial/ethnic groups Clinical disorders Cultural differences Cultural competence 


  1. Adeponle, A. B., Thombs, B. D., Groleau, D., Jarvis, E., & Kirmayer, L. J. (2012). Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients. Psychiatric Services, 63, 147–153.CrossRefGoogle Scholar
  2. Aggarwal, N. K. (2013). Cultural psychiatry, medical anthropology, and the DSM-5 field trials. Medical Anthropology: Cross-Cultural Studies in Health and Illness, 32, 393–398.CrossRefGoogle Scholar
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.CrossRefGoogle Scholar
  4. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58(5), 377–402. Scholar
  5. Anglin, D. M., & Malaspina, D. (2008). Ethnicity effects on clinical diagnoses compared to best-estimate research diagnoses in patients with psychosis: A retrospective medical chart review. Journal of Clinical Psychiatry, 69, 941–945.CrossRefGoogle Scholar
  6. Arnold, L. M., Keck Jr., P. E., Collins, J., Wilson, R., Fleck, D. E., Corey, K. B., et al. (2004). Ethnicity and first-rank symptoms in patients with psychosis. Schizophrenia Research, 67, 207–212.CrossRefGoogle Scholar
  7. Ball, K., Lawson, W., & Alim, T. (2013). Medical mistrust, conspiracy beliefs & HIV-related behavior among African Americans. Journal of Psychology and Behavioral Science, 1, 1–7.Google Scholar
  8. Barnes, A. (2004). Race, schizophrenia, and admission to state psychiatric hospitals. Administration and Policy in Mental Health, 31, 241–252.CrossRefGoogle Scholar
  9. Barnes, A. (2008). Race and hospital diagnoses of schizophrenia and mood disorders. Social Work, 53(1), 77–83. Scholar
  10. Barrio, C., Yamada, A., Atuel, H., Hough, R. L., Yee, S., Berthot, B., & Russo, P. A. (2003). A tri-ethnic examination of symptom expression on the positive and negative syndrome scale in schizophrenia spectrum disorders. Schizophrenia Research, 60, 259–269.CrossRefGoogle Scholar
  11. Bauer, S. M., Schanda, H., Karakula, H., Olajossy-Hilkesberger, L., Rudaleviciene, P., Okribelashvili, N., et al. (2011). Culture and the prevalence of hallucinations in schizophrenia. Comprehensive Psychiatry, 52, 319–325.CrossRefGoogle Scholar
  12. Bell, T. J., & Tracey, T. J. G. (2006). The relation of cultural mistrust and psychological health. Journal of Multicultural Counseling and Development, 34, 2–14.CrossRefGoogle Scholar
  13. Berg, A. O., Melle, I., Rossberg, J. I., Romm, K. L., Larsson, S., Lagerberg, T. V., et al. (2011). Perceived discrimination is associated with severity of positive and depression/anxiety symptoms in immigrants with psychosis: A cross-sectional study. BMC Psychiatry, 11, 1–9.CrossRefGoogle Scholar
  14. Blow, F. C., Zeber, J. E., McCarthy, J. F., Valenstein, M., Gillon, L., & Bingham, C. R. (2004). Ethnicity and diagnostic patterns in veterans with psychoses. Social Psychiatry and Psychiatric Epidemiology, 39, 841–851.CrossRefGoogle Scholar
  15. Bourque, F., van der Ven, E., & Malla, A. (2011). A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychological Medicine, 41, 897–910.CrossRefGoogle Scholar
  16. Brekke, J. S., & Barrio, C. (1997). Cross-ethnic symptom differences in schizophrenia: The influence of culture and minority status. Schizophrenia Bulletin, 23, 305–316.CrossRefGoogle Scholar
  17. Bresnahan, M., Begg, M. D., Brown, A., Schaefer, C., Sohler, N., Insel, B., et al. (2007). Race and risk of schizophrenia in a US birth cohort: Another example of health disparity? International Journal of Epidemiology, 36, 751–758.CrossRefGoogle Scholar
  18. Brunson, R. K., & Gau, J. M. (2015). Office race versus macro-level context: A test of competing hypotheses about black citizens’ experiences with and perceptions of black police officers. Crime and Delinquency, 6, 213–242.CrossRefGoogle Scholar
  19. Cantor-Graae, E., & Selten, J. P. (2005). Schizophrenia and migration: A meta-analysis and review. American Journal of Psychiatry, 162, 12–24.CrossRefGoogle Scholar
  20. Chang, N., Newman, J., D’Antonio, E., McKelvey, J., & Serper, M. (2011). Ethnicity and symptom expression in patients with acute schizophrenia. Psychiatry Research, 185, 453–455.CrossRefGoogle Scholar
  21. Cheng, A., & Goldstein, M. (2004). Managing schizophrenia in the African-American population. University of Toronto Medical Journal, 81, 176–178.Google Scholar
  22. Choi, M. R., Eun, H., Yoo, T. P., Yun, Y., Wood, C., Kase, M., et al. (2012). The effects of sociodemographic factors on psychiatric diagnosis. Korean Neuropsychiatric Association, 9, 199–208.Google Scholar
  23. Cohen, A., Patel, V., Thara, R., & Gureje, O. (2008). Questioning an axiom: Better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin, 34(2), 229–244. Scholar
  24. Coid, J. W., Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., & Jones, P. B. (2008). Raised incidence rates of all psychoses among migrant groups. Findings from the East London first episode psychosis study. Archives of General Psychiatry, 65, 1250–1259.CrossRefGoogle Scholar
  25. Combs, D. R., Penn, D. L., Cassisi, J., Michael, C., Wood, T., Wanner, J., & Adams, S. (2006). Perceived racism as a predictor of paranoia among African Americans. Journal of Black Psychology, 32, 87–104.CrossRefGoogle Scholar
  26. Combs, D. R., Penn, D. L., & Fenigstein, A. (2002). Ethnic differences in subclinical paranoia: An expansion of norms of the paranoia scale. Cultural Diversity and Ethnic Minority Psychology, 8, 248–256.CrossRefGoogle Scholar
  27. Comer, R. J. (2015). Abnormal psychology (9th ed.). New York: Worth Publishers.Google Scholar
  28. Contreras, J., Dassori, A., Medina, R., Raventos, H., Ontiveros, A., Nicolini, H., et al. (2009). Diagnosis of schizophrenia in latino populations. A comparison of direct interview and consensus based multi-source methods. The Journal of Nervous and Mental Disease, 197, 530–535.CrossRefGoogle Scholar
  29. Dassori, A. M., Miller, A. L., Velligan, D., Saldana, D., Diamond, P., & Mahurin, R. (1998). Ethnicity and negative symptoms in patients with schizophrenia. Cultural Diversity and Mental Health, 4, 65–69.CrossRefGoogle Scholar
  30. Delbello, M. P., Lopez-Larson, M. P., Soutullo, C. A., & Strakowski, S. M. (2001). Effects of race on psychiatric diagnosis of hospitalized adolescents: A retrospective chart review. Journal of Child and Adolescent Psychopharmacology, 11, 95–103.CrossRefGoogle Scholar
  31. Eack, S. M., & Newhill, C. E. (2012). Racial disparities in mental health outcomes after psychiatric hospital discharge among individuals with severe mental illness. Social Work Research, 36, 41–52.CrossRefGoogle Scholar
  32. Flaskerud, J. H., & Hu, L. (1992). Relationship of ethnicity to psychiatric diagnosis. Journal of Nervous and Mental Disease, 180(5), 296–303. Scholar
  33. Garb, H. N. (2005). Clinical judgment and decision making. Annual Review of Clinical Psychology, 1, 67–89.CrossRefGoogle Scholar
  34. Hagan, J., Shedd, C., & Payne, M. R. (2005). Race, ethnicity, and perceptions of criminal injustice. American Sociological Review, 70, 381–407.CrossRefGoogle Scholar
  35. Hammond, W. P. (2011). Psychosocial correlates of medical mistrust among African American men. American Journal of Community Psychology, 45, 87–106.CrossRefGoogle Scholar
  36. Haro, J. M., Novick, D., Bertsch, J., Karagianis, J., Dossenbach, M., & Jones, P. B. (2011). Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. The British Journal of Psychiatry, 199(3), 194–201. Scholar
  37. Hopper, K., & Wanderling, J. (2000). Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO collaborative followup project. Schizophrenia Bulletin, 26(4), 835–846.CrossRefGoogle Scholar
  38. Hutchinson, G., Takei, N., Sham, P., Harvey, I., & Murray, R. M. (1999). Factor analysis of symptoms in schizophrenia: Differences between White and Caribbean patients in Camberwell. Psychological Medicine, 29, 607–612.CrossRefGoogle Scholar
  39. Iacovino, J. M., Jackson, J. J., & Oltmanns, T. F. (2014). The relative impact of socioeconomic status and childhood trauma on Black-White differences in paranoid personality disorder symptoms. Journal of Abnormal Psychology, 123, 225–230.CrossRefGoogle Scholar
  40. Ihara, K., Morgan, C., Fearon, P., Dazzan, P., Demjaha, A., Lloyd, T., et al. (2009). The prevalence, diagnostic significance and demographic characteristics of schneiderian first-rank symptoms in an epidemiological sample of first-episode psychoses. Psychopathology, 42, 81–91.CrossRefGoogle Scholar
  41. Jablensky, A., Sartorius, N., Emberg, G., Anker, M., Korten, A., Cooper, J. E., et al. (1992). Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization Ten-Country Study. Psychological Medicine, s20, 1–97.Google Scholar
  42. Janssen, I., Hanssen, M., Bak, M., Bijl, R. V., De Graaf, R., Vollebergh, W., et al. (2003). Discrimination and delusional ideation. The British Journal of Psychiatry, 182(1), 71–76. Scholar
  43. Jarvis, G. E., Toniolo, I., Ryder, A. G., Sessa, F., & Cremonese, C. (2011). High rates of psychosis for black inpatients in Padua and Montreal: Different contexts, similar findings. Social Psychiatry and Psychiatric Epidemiology, 46, 247–253.CrossRefGoogle Scholar
  44. Jones, S. R., & Fernyhough, C. (2007). A new look at the neural diathesis-stress model of schizophrenia: The primacy of social-evaluative and uncontrollable situations. Schizophrenia Bulletin, 33(5), 1171–1177.CrossRefGoogle Scholar
  45. Kirkbride, J. B., Errazuriz, A., Croudace, T. J., Morgan, C., Jackson, D., Boydell, J., et al. (2012). Incidence of schizophrenia and other psychoses in England, 1950–2009: A systematic review and meta-analyses. PLoS One, 7(3), 1–21.CrossRefGoogle Scholar
  46. Kirkbride, J. B., Fearon, P., Morgan, C., Dazzan, P., Morgan, K., Tarrant, J., et al. (2006). Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: Findings from the 3-center ÆSOP study. Archives of General Psychiatry, 63(3), 250–258. Scholar
  47. Kposowa, A. J., Tsunokai, G. T., Butler, E. W., & Butle, E. W. (2002). The effects of race and ethnicity on schizophrenia: Individual and neighborhood contexts. Race, Gender, & Class, 9, 33–54.Google Scholar
  48. Kulhara, P., Shah, R., & Grover, S. (2009). Is the course and outcome of schizophrenia better in the ‘developing’ world? Asian Journal of Psychiatry, 2(2), 55–62. Scholar
  49. Lee, J., Steinberg, L., & Piquero, A. R. (2010). Ethnic identity and attitudes toward the police among African American juvenile offenders. Journal of Criminal Justice, 38, 781–789.CrossRefGoogle Scholar
  50. Lee, J., Steinberg, L., Piquero, A. R., & Knight, G. P. (2011). Identity-linked perceptions of the police among African American juvenile offenders: A developmental perspective. Journal of Youth Adolescence, 40, 23–37.CrossRefGoogle Scholar
  51. McKenzie, K. (2006). Racial discrimination and mental health. Psychiatry, 5, 383–387.CrossRefGoogle Scholar
  52. Miller, P. R., Dasher, R., Collins, R., Griffiths, P., & Brown, F. (2001). Inpatient diagnostic assessment: Accuracy of structured vs. unstructured interviews. Psychiatry Research, 105, 255–264.CrossRefGoogle Scholar
  53. Minsky, S., Vega, W., Miskimen, T., Gara, M., & Escobar, J. (2003). Diagnostic patterns in Latino, African-American, and European American psychiatric patients. Archive of General Psychiatry, 60, 637–644.CrossRefGoogle Scholar
  54. Morgan, C., Kirkbride, J., Leff, J., Craig, T., Hutchinson, G., McKenzie, K., et al. (2007). Parental separation, loss and psychosis in different ethnic groups: A case-control study. Psychological Medicine, 37(4), 495–503. Scholar
  55. Morgan, C., Reininghaus, U., Fearon, P., Hutchinson, G., Morgan, K., Dazzan, P., et al. (2014). Modelling the interplay between childhood and adult adversity in pathways to psychosis: Initial evidence from the AESOP study. Psychological Medicine, 44(2), 407–419. Scholar
  56. Neighbors, H. W., Trierweiler, S. J., Ford, B. C., & Muroff, J. R. (2003). Racial differences in DSM diagnoses using a semi-structured instrument: The importance of clinical judgment in the diagnosis of African Americans. Journal of Health and Social Behavior, 44, 237–256.CrossRefGoogle Scholar
  57. Neighbors, H. W., Trierweiler, S. J., Munday, C., Thompson, E. E., Jackson, J. S., Binion, V. J., & Gomez, J. (1999). Psychiatric diagnosis of African-Americans: Diagnostic divergence in clinician-structured and semistructured interviewing conditions. Journal of the National Medical Association, 91, 601–612.PubMedPubMedCentralGoogle Scholar
  58. Reininghaus, U. A., Morgan, C., Simpson, J., Dazzan, P., Morgan, K., Doody, G. A., et al. (2008). Unemployment, social isolation, achievement-expectation mismatch and psychosis: Findings from the Æsop study. Social Psychiatry and Psychiatric Epidemiology, 43(9), 743–751. Scholar
  59. Rice, N., & O’Donohue, W. (2002). Cultural sensitivity: A critical examination. New Ideas in Psychology, 20, 35–48.CrossRefGoogle Scholar
  60. Sartorius, N., Jablensky, A., Korten, A., Ernberg, G., Anker, M., Cooper, J. E., & Day, R. (1986). Early manifestations and first-contact incidence of schizophrenia in different cultures. A preliminary report on the initial evaluation phase of the WHO Collaborative Study on determinants of outcome of severe mental disorders. Psychological Medicine, 16, 909–928.CrossRefGoogle Scholar
  61. Schwartz, R. C., & Feisthamel, K. P. (2009). Disproportionate diagnosis of mental disorders among African American versus European American clients: Implications for counseling theory, research, and practice. Journal of Counseling and Development, 87, 295–301.CrossRefGoogle Scholar
  62. Sharpley, M., Hutchinson, G., McKenzie, K., & Murray, R. M. (2001). Understanding the excess of psychosis among the African-Caribbean population in England. British Journal of Psychiatry, 178, s60–s68.CrossRefGoogle Scholar
  63. Sharpley, M. S., & Peters, E. R. (1999). Ethnicity, class and schizotypy. Social Psychiatry and Psychiatric Epidemiology, 34, 507–512.CrossRefGoogle Scholar
  64. Silverstein, S. M., Moghaddam, B., & Wykes, T. (2013). Schizophrenia: Evolution and synthesis. Cambridge, MA: MIT Press. Scholar
  65. Snowden, L. R., Hastings, J. F., & Alvidrez, J. (2009). Overrepresentation of Black Americans in psychiatric inpatient care. Psychiatric Services, 60, 779–785.CrossRefGoogle Scholar
  66. Sohler, N. L., & Bromet, E. J. (2003). Does racial bias influence psychiatric diagnoses assigned at first hospitalization? Social Psychiatry and Psychiatric Epidemiology, 38, 463–472.CrossRefGoogle Scholar
  67. Stilo, S. A., & Murray, R. M. (2010). The epidemiology of schizophrenia: Replacing dogma with knowledge. Dialogues in Clinical Neuroscience, 12(3), 305–315.PubMedPubMedCentralGoogle Scholar
  68. Strakowski, S. M., Flaum, M., Amador, M., Bracha, H. S., Pandurangi, A. K., Robinson, D., & Tohen, M. (1996). Racial differences in the diagnosis of psychosis. Schizophrenia Research, 21, 117–124.CrossRefGoogle Scholar
  69. Strakowski, S. M., Keck Jr., P. E., Arnold, L. M., Collins, J., Wilson, R. M., Fleck, D. E., et al. (2003). Ethnicity and diagnosis in patients with affective disorders. Journal of Clinical Psychiatry, 64, 747–754.CrossRefGoogle Scholar
  70. Strakowski, S. M., McElroy, S. L., Keck Jr., P. E., & West, S. A. (1996). Racial influence on diagnosis in psychotic mania. Journal of Affective Disorders, 39, 157–162.CrossRefGoogle Scholar
  71. Suhail, K., & Cochrane, R. (2002). Effect of culture and environment on the phenomenology of delusions and hallucinations. International Journal of Social Psychiatry, 48, 126–138.CrossRefGoogle Scholar
  72. Trierweiler, S. J., Muroff, J. R., Jackson, J. S., Neighbors, H. W., & Munday, C. (2005). Clinician race, situational attributions, and diagnostic decisions of schizophrenia-type and mood-type disorders. Cultural Diversity & Ethnic Minority Psychology, 11, 351–364.CrossRefGoogle Scholar
  73. Trierweiler, S. J., Neighbors, H. W., Munday, C., Thompson, E. E., Jackson, J. S., & Binion, V. J. (2006). Differences in patterns of symptom attribution in diagnosing schizophrenia between African Americans and non-African American clinicians. American Journal of Orthopsychiatry, 76, 154–160.CrossRefGoogle Scholar
  74. Vega, W. A., Sribney, W. M., Miskimen, T. M., Escobar, J. I., & Aguilar-Gaxiola, S. (2006). Putative psychotic symptoms in the Mexican American population. Prevalence and co-occurrence with psychiatric disorders. The Journal of Nervous and Mental Disease, 194, 471–477.CrossRefGoogle Scholar
  75. Veling, W. (2014). Ethnic minority position and risk for psychotic disorders. Current Opinions Psychiatry, 26, 166–171.CrossRefGoogle Scholar
  76. Walker, E., Mittal, V., & Tessner, K. (2008). Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Annual Review of Clinical Psychology, 4, 189–216.CrossRefGoogle Scholar
  77. Weiser, M., Werbeloff, N., Vishna, T., Yoffee, R., Lubin, G., Shmushkevitch, M., & Davidson, M. (2008). Elaboration on immigration and risk for schizophrenia. Psychological Medicine, 38, 1113–1119.CrossRefGoogle Scholar
  78. Weisman, A. G. (1997). Understanding cross-cultural prognostic variability for schizophrenia. Cultural Diversity and Mental Health, 3(1), 23.CrossRefGoogle Scholar
  79. Weisman, A. G., & López, S. R. (1996). Family values, religiosity, and emotional reactions to schizophrenia in Mexican and Anglo-American Cultures. Family Process, 35, 227–237.CrossRefGoogle Scholar
  80. Weisman, A. G., & López, S. R. (1997). An attributional analysis of emotional reactions to schizophrenia in Mexican and Anglo American cultures. Journal of Applied Social Psychology, 27(3), 223–244.CrossRefGoogle Scholar
  81. Weisman, A., Rosales, G., Kymalainen, J., & Armesto, J. (2005). Ethnicity, Family Cohesion, Religiosity and General Emotional Distress in Patients with Schizophrenia and Their Relatives. Journal of Nervous and Mental Disease, 193, 359–368.CrossRefGoogle Scholar
  82. Weisman, A. G., Lopez, S. R., Ventura, J., Nuechterlein, K. H., Goldstein, M. J., & Hwang, S. (2000). A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia. Schizophrenia Bulletin, 26, 817–824.CrossRefGoogle Scholar
  83. Weisman de Mamani, A., & Caldas, T. (2013). A comparison of positive and negative symptom types in Anglo, Latino, and African-American patients with schizophrenia. Interamerican Journal of Psychology, 3, 111–116.Google Scholar
  84. Whaley, A. L. (1997). Ethnicity/race, paranoia, and psychiatric diagnoses: Clinician bias versus sociocultural differences. Journal of Psychopathology and Behavioral Assessment, 19, 1–20.CrossRefGoogle Scholar
  85. Whaley, A. L. (1998). Cross-cultural perspective on paranoia: A focus on the black American experience. Psychiatric Quarterly, 69, 325–343.CrossRefGoogle Scholar
  86. Whaley, A. L. (2001). Cultural mistrust: An important psychological construct for diagnosis and treatment of African Americans. Professional Psychology: Research and Practice, 32, 555–562.CrossRefGoogle Scholar
  87. Whaley, A. L. (2002). Cultural mistrust predicts age at first hospitalization for African-American psychiatric patients. The Journal of Nervous and Mental Disease, 190, 121–124.CrossRefGoogle Scholar
  88. Whaley, A. L., & Hall, B. N. (2008). The cultural/racial dimension of psychotic disorders in African American patients. Journal of Black Psychology, 34, 494–505.CrossRefGoogle Scholar
  89. Whaley, A. L., & Hall, B. N. (2009a). Cultural themes in the psychotic symptoms of African American psychiatric patients. Professional Psychology, 40, 75–80.CrossRefGoogle Scholar
  90. Whaley, A. L., & Hall, B. N. (2009b). Effects of cultural themes in psychotic symptoms on the diagnosis of schizophrenia in African Americans. Mental Health, Religion, & Culture, 12, 457–471.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Kayla Gurak
    • 1
  • Jessica Maura
    • 1
  • Amy Weisman de Mamani
    • 1
  • Ana Martinez de Andino
    • 1
  • Irwin Rosenfarb
    • 2
  1. 1.University of Miami, Department of PsychologyCoral GablesUSA
  2. 2.California School of Professional PsychologyAlliant International UniversitySan DiegoUSA

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