Men, Women at Risk for Psychosis Differ in Subjective Experience

The subjective experience of young people at high risk for psychosis reveals significant differences in the way men and women describe their troubled inner world, according to a report published September 2 in Psychiatric Services in Advance.

Specifically, men at risk described alienation and despair, with escape through fantasy, although with a continued desire for social connection. By contrast, women at risk described social engagement and career aspirations, while dealing with the sadness and pain of ill family members and past trauma.

Cheryl Corcoran, M.D., M.S., of the Department of Psychiatry at Columbia University and the New York State Psychiatric Institute and colleagues said that understanding the different ways young men and women subjectively experience their struggles can help in tailoring outreach programs and treatments that will appeal to them and keep them engaged.

“Males experienced negative symptoms and depression as alienation and despair. Attenuated psychotic symptoms for males were interpreted as going ‘crazy,’ ” they said. “The existential pain for them was such that they sought escape, largely into fantasy. This constellation poses a significant challenge for treatment and recovery, because it reflects low self-esteem (‘broken’) and maladjusted coping (‘escape’); however, their desire to have relationships represents a potential base for forming treatment alliances in supportive and behaviorally based therapy. Outreach to males via the Internet may be useful, given their isolation. By contrast, the females in our study were largely pragmatic and future oriented, in the process of building a career, juggling obligations to others, and grappling with the emotional aftermath of trauma. Females might benefit from treatment services with extended hours that accommodate their busy days of work and school and from more trauma-oriented therapy focused on emotion regulation.”

The researchers conducted audiotaped interviews from 2007 to 2012 with 27 participants of diverse racial and ethnic backgrounds who were at clinically high risk of psychosis (15 males and 12 females; mean age 21). Participants were identified as being at clinically high risk of psychosis on the basis of attenuated or subthreshold psychotic symptoms as measured by the Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms.

Qualitative data were collected through open-ended, narrative interviews. Participants were queried in regard to the following areas, and interviewers asked additional clarifying questions if they were not discussed spontaneously: What changes have you perceived over time? How have you been affected by these changes? What has been helpful or not? What are your expectations for the future?

The research revealed important differences in the way the men and the women perceived their lives and futures. Five men described feeling “broken” or “abnormal,” which they ascribed to genes, abnormal development, or immigration issues. One said, “Maybe in my head something did not develop properly or there is something missing. If I had never come to the United States, maybe I would not be the same person I am now. I would be more normal.”

The fantasy of escape was common among men. One said, “I fantasize about living in worlds with different laws of physics, different cultures, societies, ways of life, everything. What would it be like to live like an animal?” And half of the men described withdrawal, such as spending hours surfing the Web and playing video games instead of going to class, sleeping more, or living like “a hermit.”

Several of the men described alienation and despair. One said, “The future feels bleak. I feel pointless right now. I’m getting old. I didn’t finish college. I don’t have a girlfriend, never really had a girlfriend. …”

Other themes were evident among the women in the study. Seven described psychosis of a family member, usually their mothers. All the women with a documented family history of psychosis (ascertained in the prodromal research program) brought this up spontaneously. Eight women cited a history of trauma, including neglect, abuse, parental separation, and witnessing violence. One woman said, “I grew up completely neglected and abused. They didn’t explain to me why I was getting hit.” Another described her childhood: “There was one summer we went like entirely without food. We lived in a homeless shelter for a year.”

Seven women described motivation and plans for a career. One said, “Most of my life, kind of the goal I have for myself was just being able to be independent in any way, to have a little apartment—it’s kind of like my ultimate goal.”

John Strauss, M.D., a professor emeritus of psychiatry at Yale University, who reviewed the study, has studied the subjective experience of patients with psychiatric illness.

“Subjectivity in schizophrenia, whether early in its course, during an episode, or in the improvement process is crucial and goes well beyond the existence of symptoms to include a large range of human experience,” he told Psychiatric News. “For example, people with early schizophrenia and with full-blown schizophrenia often report the horrifying feeling that their sense of who they are is falling apart or that their sense of the nature of the world is disintegrating. Many people who improve describe the importance of factors like the sense of accomplishment from working, that ‘someone took me seriously’ or ‘someone cared about me’ as central to the improvement process.”

But Strauss said subjective experience has tended to be devalued in contemporary, data-driven practice. “Since these experiences are difficult to measure and are not considered central in the narrow version of the medical model, they are often treated by professionals as though they were irrelevant or even nonexistent,” he said. “Research such as [the study by Corcoran and colleagues] is essential to exploring such factors and more generally to understanding these broader areas of subjectivity that are so often ignored and are little understood.”

The researchers said that the relatively preserved social and role function, especially among women at risk, is a novel finding and has implications for designing outreach and treatment strategies. “Further qualitative research is needed to confirm gender differences and to better understand subjective experience and phenomenology in the at-risk state … for improving preventive interventions and service delivery for individuals at risk,” they said. ■