Display options
Share it on

Psychol Psychother. 2021 Sep;94(3):704-720. doi: 10.1111/papt.12317. Epub 2020 Nov 20.

How psychosis interrupts the lives of women and men differently: a qualitative comparison.

Psychology and psychotherapy

Ruth L Firmin, Aieyat B Zalzala, Jay A Hamm, Lauren Luther, Paul H Lysaker

Affiliations

  1. Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, Rhode Island, USA.
  2. Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island, USA.
  3. Department of Psychiatry, The Institute of the Living at Hartford Hospital, Hartford, Connecticut, USA.
  4. Midtown Community Mental Health Center, Eskenazi Hospital, Indianapolis, Indiana, USA.
  5. Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.
  6. Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.
  7. Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA.
  8. Roudebush VA Medical Center, Indianapolis, Indiana, USA.

PMID: 33215851 DOI: 10.1111/papt.12317

Abstract

PURPOSE: Psychosis disrupts how persons experience themselves and their lives. Despite knowledge that gender differences have been noted in presentation and course of psychosis symptoms, little is known about differences in how men and women experience these disruptions.

METHOD: The narratives of 26 men and 27 women diagnosed with psychosis, matched on age, education, and race, of the impact of psychosis on one's life, were compared. Using secondary data from semi-structured interviews, themes were identified using inductive, phenomenological qualitative analyses.

RESULTS: Women and men discussed psychosis-related interruptions to the roles and relationships that shape their identity. Both genders discussed the impact of psychosis on their sense of self, work, and relationships. Nuanced gender differences emerged, informing unique areas of challenge related to (1) parenting and loss of parenting roles, (2) work and loss or changes in work trajectories, (3) isolation and strain on interpersonal relationships, and (4) manifestations of stigma.

CONCLUSIONS: Psychosis may disrupt distinct aspects of life for men and women. Each gender faces the intersection of socially informed expectations that impact one's experiences of stigma, expectations of others, and manifestations of losses felt in one's role and sense of identity. Findings inform important considerations for therapy and other services.

PRACTITIONER POINTS: Gender-based socialized expectations, losses, and challenges that accompany psychosis are important areas for therapeutic consideration. Current treatments may neglect challenges that are more commonly experienced by women with psychosis.

© 2020 British Psychological Society.

Keywords: gender; identity; parenting; psychosis; schizophrenia; sense of self; stigma; work

References

  1. Abu-Akel, A., & Bo, S. (2013). Superior mentalizing abilities of female patients with schizophrenia. Psychiatry Research, 210, 794-799. https://doi.org/10.1016/j.psychres.2013.09.013 - PubMed
  2. Aleman, A., Kahn, R.S., & Selten, J.P. (2003). Sex differences in the risk of schizophrenia: Evidence from meta-analysis. Archives of General Psychiatry, 60, 565-571. https://doi.org/10.1001/archpsyc.60.6.565 - PubMed
  3. Andresen, R., Oades, L., & Caputi, P. (2003). The experience of recovery from schizophrenia: Towards an empirically validated state model. Australian and New Zealand Journal of Psychiatry, 37, 586-594. https://doi.org/10.1046/j.1440-1614.2003.01234.x - PubMed
  4. Angermeyer, M.C., & Kühnz, L. (1988). Gender differences in age at onset of schizophrenia. European Archives of Psychiatry and Neurological Sciences, 237, 351-364. https://doi.org/10.1007/bf00380979 - PubMed
  5. Bargenquast, R., & Schweitzer, R.D. (2014). Enhancing sense of recovery and self-reflectivity in people with schizophrenia: a pilot study of metacognitive narrative psychotherapy. Psychology and Psychotherapy: Theory, Research and Practice, 87, 338-356. https://doi.org/10.1111/papt.12019 - PubMed
  6. Barker-Collo, S., & Read, J. (2011). The roles of gender and coping styles in the relationship between child abuse and the SCL-90-R subscales' psychoticism' and 'paranoid ideation'. New Zealand Journal of Psychology (Online), 40, 30-40. https://psycnet.apa.org/record/2012-16687-003 - PubMed
  7. Berg, B.L. (2001). Qualitative research methods for the social sciences, 8th ed. Boston: Allyn & Bacon. - PubMed
  8. Bleuler, E. (1911/1950). Dementia praecox or the group of schizophrenias. New York, NY: International Universities Press. - PubMed
  9. Bonfils, K.A., Adams, E.L., Firmin, R.L., White, L.M., & Salyers, M.P. (2014). Parenthood and severe mental illness: Relationships with recovery. Psychiatric Rehabilitation Journal, 37, 186-193. https://doi.org/10.1037/prj0000072 - PubMed
  10. Boyle, M. (1997). Making gender visible in clinical psychology. Feminism & Psychology, 7, 231-238. - PubMed
  11. Canuso, C., & Pandina, G. (2007). Gender and schizophrenia. Psychopharmacology Bulletin, 40, 178-190. - PubMed
  12. Carr, E.R., Green, B., & Ponce, A.N. (2015). Women and the experience of serious mental illness and sexual objectification: Multicultural feminist theoretical frameworks and therapy recommendations. Women & Therapy, 38(1-2), 53-76. https://doi.org/10.1080/02703149.2014.978216 - PubMed
  13. Chaplin, T.M., Cole, P.M., & Zahn-Waxler, C. (2005). Parental socialization of emotion expression: gender differences and relations to child adjustment. Emotion, 5(1), 80-88. https://doi.org/10.1037/1528-3542.5.1.80 - PubMed
  14. Denham, S.A., Zoller, D., & Couchoud, E.A. (1994). Socialization of preschoolers' emotion understanding. Developmental Psychology, 30, 928-936. https://doi.org/10.1037/0012-1649.30.6.928 - PubMed
  15. Diaz-Caneja, A., & Johnson, S. (2004). The views and experiences of severely mentally ill mothers: A qualitative analysis. Social Psychiatry and Psychiatric Epidemiology, 39, 472-482. https://doi.org/10.1007/s00127-004-0772-2 - PubMed
  16. Firmin, R.L., Luther, L., Lysaker, P.H., Minor, K.S., McGrew, J.H., Cornwell, M.N. & Salyers, M.P.(2017). Stigma resistance at the personal, peer, and public levels: A new conceptual model. Stigma and Health, 2, 182-194. https://doi.org/10.1037/sah0000054 - PubMed
  17. Garrett, N.R. (2004). Treatment of a transgender client with schizophrenia in a public psychiatric milieu: A case study by a student therapist. Journal of Gay & Lesbian Psychotherapy, 8(3-4), 127-141. https://doi.org/10.1300/j236v11n01_06 - PubMed
  18. Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press. - PubMed
  19. Goldstein, J.M., & Tsuang, M.T. (1990). Gender and schizophrenia: An introduction and synthesis of findings. Schizophrenia Bulletin, 16, 263-275. https://doi.org/10.1093/schbul/16.2.179 - PubMed
  20. Haarmans, M. (2019a). Everything you always wanted to know about sex [and gender] in psychosis but were afraid to ask: A review. In M. Sáenz-Herrero (Ed.), Psychopathology in women - incorporating gender perspectives into descriptive psychopathology (pp. 361-387). Cham: Springer. https://doi.org/10.1007/978-3-030-15179-9_18 - PubMed
  21. Haarmans, M. (2019b). Improving our science with a sex- and gender-based analysis in psychosis research. In M. Sáenz-Herrero (Ed.), Psychopathology in women - incorporating gender perspectives into descriptive psychopathology, 2nd ed. (pp. 83-110). Cham: Springer. https://doi.org/10.1007/978-3-030-15179-9_6 - PubMed
  22. Haarmans, M., McKenzie, K., Kidd, S.A., & Bentall, R.P. (2018). Gender role strain, core schemas, and psychotic experiences in ethnically diverse women: A role for sex-and gender-based analysis in psychosis research? Clinical Psychology & Psychotherapy, 25, 774-784. https://doi.org/10.1002/cpp.2307 - PubMed
  23. Haarmans, M., Vass, V., & Bentall, R.P. (2016). Voices’ use of gender, race and other social categories to undermine female voice-hearers: Implications for incorporating intersectionality within CBT for psychosis. Psychosis, 8, 203-213. https://doi.org/10.1080/17522439.2015.1131323 - PubMed
  24. Häfner, H., Behrens, S., De Vry, J., & Gattaz, W.F. (1991). An animal model for the effects of estradiol on dopamine-mediated behavior: Implications for sex differences in schizophrenia. Psychiatry Research, 38, 125-134. https://doi.org/10.1016/0165-1781(91)90038-q - PubMed
  25. Hewitt-Taylor, J. (2001). Use of constant comparative analysis in qualitative research. Nursing Standard, 15, 39-42. https://doi.org/10.7748/ns2001.07.15.42.39.c3052 - PubMed
  26. Hill, C.E. (2012). Consensual qualitative research: A practical resource for investigating social science phenomena. Washington, DC: American Psychological Association. - PubMed
  27. Hill, C.E., Knox, S., Thompson, B.J., Williams, E.N., Hess, S.A., & Ladany, N. (2005). Consensual qualitative research: An update. Journal of Counseling Psychology, 52, 196. https://doi.org/10.1037/0022-0167.52.2.196 - PubMed
  28. Johnson, J.L., & Repta, R. (2012). Sex and gender: beyond the binaries. In J.L. Oliffe & L. Greaves (Eds.), Designing and conducting gender, sex, & health research (pp. 39-64). Los Angeles: Sage Publications Inc. https://doi.org/10.4135/9781452230610.n2 - PubMed
  29. Jones, D., Marcias, R., Gold, P.B., Barreira, P. & Fisher, W.(2008). When parents with severe mental illness lose contact with their children: Are psychiatric symptoms or substance use to blame? Journal of Loss and Trauma, 13, 261-287. https://doi.org/10.1080/15325020701741849 - PubMed
  30. Jones, N., Rosen, C., Kamens, S., & Shattell, M. (2018). “It was definitely a sexual kind of sensation”: Sex, sexual identity, and gender in the phenomenology of psychosis. Psychosis, 10, 122-131. https://doi.org/10.1080/17522439.2018.1469036 - PubMed
  31. Kean, C.S. (2009). Silencing the self: Schizophrenia as a self-disturbance. Schizophrenia Bulletin, 35, 1034-1036. https://doi.org/10.1093/schbul/sbp043 - PubMed
  32. Koestner, R., & Aube, J. (1995). A multifactorial approach to the study of gender characteristics. Journal of Personality, 63, 681-710. - PubMed
  33. Laing, R.D. (1988/1959). The divided self: An existential study in sanity and madness. London, UK: Penguin Books. - PubMed
  34. Lampshire, D. (2012). The sounds of a wounded world. In J. Geekie, P. Randal, D. Lampshire & J. Read (Eds.), Experiencing psychosis: Personal and professional perspectives (pp. 139-145). New York, NY: Routledge. https://doi.org/10.1002/j.2167-4086.2013.00045.x - PubMed
  35. Lauveng, A. (2012). When you have lost yourself, there's really not very much left. In J. Geekie, P. Randal, D. Lampshire & J. Read (Eds.), Experiencing psychosis: Personal and professional perspectives (pp. 79-86). New York, NY: Routledge. - PubMed
  36. Levant, R.F. (2011). Research in the psychology of men using the gender role strain paradigm as a framework. American Psychologist, 66, 765-776. https://doi.org/10.1037/a0025034 - PubMed
  37. Lewine, R.R. (1981). Sex differences in schizophrenia: timing or subtypes? Psychological Bulletin, 90, 432-444. https://doi.org/10.1037/0033-2909.90.3.432 - PubMed
  38. Lysaker, P.H., Buck, K.D., Taylor, A.C., & Roe, D. (2008). Associations of metacognition and internalized stigma with quantitative assessments of self-experience in narratives of schizophrenia. Psychiatry Research, 157(1), 31-38. https://doi.org/10.1016/j.psychres.2007.04.023 - PubMed
  39. Lysaker, P.H., Clements, C.A., Plascak-Hallberg, C.D., Knipscheer, S.J., & Wright, D.E. (2002). Insight and personal narratives of illness in schizophrenia. Psychiatry, 65, 197-206. https://doi.org/10.1521/psyc.65.3.197.20174 - PubMed
  40. Lysaker, P.H., Dimaggio, G., Daroyanni, P., Buck, K.D., LaRocco, V.A., Carcione, A., & Nicolo, G. (2010). Assessing metacognition in schizophrenia with the Metacognition Assessment Scale: Associations with the Social Cognition and Object Relations Scale. Psychology and Psychotherapy: Theory, Research and Practice, 83, 303-315. https://doi.org/10.1348/147608309x481117 - PubMed
  41. Lysaker, P.H., Hamm, J.A., Vohs, J., Kukla, M., Pattison, M., Leonhardt, B., & Lysaker, J.T. (2018). Understanding the course of self-disorders and alterations in self-experience in schizophrenia: Implications from research on metacognition. Current Psychiatry Reviews, 14, 160-170. https://doi.org/10.2174/1573400514666180816113159 - PubMed
  42. Lysaker, P.H., & Klion, R. (2017). Recovery, meaning-making, and severe mental illness: A comprehensive guide to metacognitive reflection and insight therapy. New York: Routledge. - PubMed
  43. Lysaker, P.H., & Lysaker, J.T. (2010). Schizophrenia and alterations in self-experience: A comparison of 6 perspectives. Schizophrenia Bulletin, 36, 331-340. https://doi.org/10.1093/schbul/sbn077 - PubMed
  44. Lysaker, P.H., Roe, D., & Buck, K.D. (2009). Recovery and wellness amidst schizophrenia: Definitions, evidence and the implications for clinical practice. Journal of the American Psychiatric Nurses Association, 16(1), 36-43. https://doi.org/10.1177/1078390309353943 - PubMed
  45. Lysaker, P.H., Roe, D., & Kukla, M. (2012). Psychotherapy and rehabilitation for schizophrenia: Thoughts about their parallel development and potential integration. Journal of Psychotherapy Integration, 22, 344. https://doi.org/10.1037/a0029580 - PubMed
  46. Mendrek, A., & Mancini-Marïe, A. (2015). Sex/gender differences in the brain and cognition in schizophrenia. Neuroscience & Biobehavioral Reviews, 67, 57-78. https://doi.org/10.1016/j.neubiorev.2015.10.013 - PubMed
  47. Moernaut, N., Vanheule, S., & Feyaerts, J. (2018). Content matters: A qualitative analysis of verbal hallucinations. Frontiers in Psychology, 9, 1958. https://doi.org/10.3389/fpsyg.2018.01958 - PubMed
  48. Mowbray, C.T., Oyserman, D., Bybee, D., MacFarlane, P., & Rueda-Riedel, A. (2001). Life circumstances of mothers with serious mental illnesses. Psychiatric Rehabilitation Journal, 25, 114-123. https://doi.org/10.1037/h0095034 - PubMed
  49. Nassar, E.H., Walders, N., & Jankins, J.H. (2002). The experience of schizophrenia: What's gender got to do with it? A critical review of the current status of research on schizophrenia. Schizophrenia Bulletin, 28, 351-362. https://doi.org/10.1093/oxfordjournals.schbul.a006944 - PubMed
  50. Nicholson, J., Biebel, K., Hinden, B.R., Henry, A.D., & Stier, L. (2001). Critical issues for parents with mental illness and their families. Rockville, MD: Center for Mental Health Services/Substance Abuse and Mental Health Services Administration. - PubMed
  51. Nicholson, J., Biebel, K., Katz-Leavy, J., & Williams, V. (2002). The prevalence of parenthood in adults with mental illness: Implications for state and federal policymakers, programs, and providers. In R.W. Manderscheid & M.J. Henderson (Eds.), Mental health, United States, 2002 (pp. 120-137). Rockville, MD: Substance Abuse and Mental Health Services Administration. - PubMed
  52. Nicholson, J., Nason, M.W., Calabresi, A.O., & Yando, R. (1999). Fathers with severe mental illness: Characteristics and comparisons. American Journal of Orthopsychiatry, 69, 134-141. https://doi.org/10.1037/h0080390 - PubMed
  53. Ochoa, S., Usall, J., Cobo, J., Labad, X., & Kulkarni, J. (2012). Gender differences in schizophrenia and first-episode psychosis: A comprehensive literature review. Schizophrenia Research and Treatment, 4, 1-12. https://doi.org/10.1155/2012/916198 - PubMed
  54. Riecher-Rössler, A., Butler, S., & Kulkarni, J. (2018). Sex and gender differences in schizophrenic psychoses-a critical review. Archives of Women's Mental Health, 21, 627-648. https://doi.org/10.1007/s00737-018-0847-9 - PubMed
  55. Rodgers, B. (2008). Audit trail. In L. Given (Ed.), The Sage encyclopedia of qualitative research methods, Vol. 1 (pp. 43-44). Thousand Oaks, CA: Sage. - PubMed
  56. Sajatovic, M., Jenkins, J.H., Strauss, M.E., Butt, Z.A., & Carpenter, E. (2005). Gender identity and implications for recovery among men and women with schizophrenia. Psychiatric Services, 56(1), 96-98. https://doi.org/10.1176/appi.ps.56.1.96 - PubMed
  57. Seeman, M.V. (1983). Schizophrenic men and women require different treatment programs. Journal of Psychiatric Treatment Evaluation, 5, 143-148. - PubMed
  58. Seeman, M.V. (1997). Psychopathology in women and men: Focus on female hormones. American Journal of Psychiatry, 12, 1641-1647. - PubMed
  59. Seeman, M.V., & Lang, M. (1990). The role of estrogens in schizophrenia gender differences. Schizophrenia Bulletin, 16, 185-194. - PubMed
  60. Shtasel, D.L., Gur, R.E., Gallacher, F., Heimberg, C., & Gur, R.C. (1997). Gender differences in the clinical expression of schizophrenia. Schizophrenia Research, 7, 225-231. - PubMed
  61. Smith, J.A., & Shinebourne, P. (2012). Interpretative phenomenological analysis. In H. Cooper, P.M. Camic, D.L. Long, A.T. Panter, D. Rindskopf & K.J. Sher (Eds.), APA handbook of research methods in psychology, Vol. 2. Research designs: Quantitative, qualitative, neuropsychological, and biological (pp. 73-82). Washington, DC: American Psychological Association. - PubMed
  62. Spitzer, R.L., Williams, J.B., Gibbon, M., & First, M. (1994). Structured clinical interview for DSM-IV. New York, NY: Biometrics Research Department. - PubMed
  63. Szymanski, S., Lieberman, J.A., Alvir, J.M., Mayerhoff, D., Loebel, A., Geisler, S., … Woerner, M. (1995). Gender differences in onset of illness, treatment response, course, and biologic indexes in first-episode schizophrenic patients. American Journal of Psychiatry, 152, 698-703. https://doi.org/10.1176/ajp.152.5.698 - PubMed
  64. Thorup, A., Petersen, L., Jeppesen, P., Ohlenschlaeger, J., Christensen, T., Krarup, G., … Nordentoft, M. (2007). Gender differences in young adults with first-episode schizophrenia spectrum disorders at baseline in the Danish OPUS study. Journal of Nervous and Mental Disease, 195, 396-405. https://doi.org/10.1097/01.nmd.0000253784.59708.dd - PubMed
  65. Wertz, F.J. (2008). A Comparison of Analytic Methods in Phenomenology, Grounded Theory, Discourse Analysis, Narrative Psychology and Intuitive Inquiry. In Proceedings from 115th Annual APA Convention, Boston - PubMed
  66. White, L.M., McGrew, J.H., & Salyers, M.P. (2013). Parents served by assertive community treatment: parenting needs, services, and attitudes. Psychiatric Rehabilitation, 36, 22-27. https://doi.org/10.1037/h0094743 - PubMed
  67. Wirth, J.H., & Bodenhausen, G.V. (2009). The role of gender in mental-illness stigma: A National Experiment. Psychological Science, 20, 169-173. https://doi.org/10.1111/j.1467-9280.2009.02282.x - PubMed

MeSH terms

Publication Types