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\title{Gender and Schizophrenia}
\author{Marc Horowitz}
\date{29 November 1995}
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Schizophrenia is a type of psychological disorder which affects both
men and women. Although the same symptoms are found in both men and
women, the distribution and cause of the various symptoms are
frequently related to gender.  One way in which the differences
between the genders are manifested is in sensitivity to variations in
cerebral anatomy.  Men are more susceptible than women to cerebral
abnormalities which correlate with schizophrenia.  This leads to more
severe symptoms in men, since the cerebral differences almost always
have other detrimental effects as well.  Other differences linked to
sex exist, although the physiological reasons are not known.  This
dichotomy between men and women indicates that the nature of the
disease in men and women may be substantially different.  One possible
conclusion is that making prevention and treatment methods specific to
each gender could be more effective.

The differences between schizophrenic men and women are thought to
begin during fetal development.  Twelve to eighteen weeks after
conception, the male fetus begins producing its own testosterone,
resulting in the first gender differences in fetal cerebral
development (McEwen, 1981, as cited in Seeman and Lang, 1990).  The
most significant result which is relevant to schizophrenia is that the
female brain begins developing earlier.  As a result, the female brain
is more fully developed at birth, making it less susceptible to birth
trauma.  The greater occurrence of birth trauma in boys appears to be
a contributor to the earlier age of onset of schizophrenia in males
(Seeman and Lang, 1990).

The earlier age of onset of schizophrenia in men has been observed in
several studies.  Forrest and Hay (1971, cited in Flor-Henry, 1990)
investigated the number of schizophrenic patients admitted to a
hospital in Edinburgh.  For patients below the age of thirty, the
ratio of men to women was approximately eight to five.  For patients
above the age of forty, the ratio dropped to 1 to 3.  More recently,
Loranger (1984, cited in Flor-Henry, 1990) evaluated the onset of
schizophrenia in one hundred men and one hundred women.  Of these,
ninety men and twenty or thirty women became ill before the age of
thirty.  On the other hand, of the patients who began exhibiting
symptoms after the age of 35, seventeen were women but only two were
men.  This phenomenon of a crossover around the age of 35-40 is not
limited to western cultures.  Similar results have been found in
Poland (Majczak et al., 1981, cited in Flor-Henry, 1990) and Ghana
(Sikanartey and Eaton, 1984, cited in Flor-Henry, 1990).

This early beginning in men has far-reaching clinical effects.
Early-onset schizophrenia occurs during late adolescence in men, and
about five years later in women.  This difference is critical, as the
earlier symptoms begin to appear, the more interruption of critical
stages of cognitive and psychological development occurs (Seeman and
Lang, 1990).  The practical effect of this is that men tend to have
worse symptoms and a more chronic course of the disease.  After a
first hospitalization, women tend to be rehospitalized at a lesser
rate, a smaller number of times, and for a shorter duration when they
are hospitalized.  They also are more successful at adapting
themselves back into society after getting out of the hospital, and
are more likely to be employed and married. (Angermeyer et al., 1990).
All of this seems to be due to the fact that early-onset
schizophrenics never enjoy normal social development, so rather than
reacclimating to society after some time in treatment, they must
acclimate for the first time.

For the earliest schizophrenics, this might never happen.  In a
longitudinal study of young adults diagnosed with schizophrenia (Test
et al., 1990), after about nine years of the study, nine of 121
subjects had committed suicide.  Of these, eight were male, and their
average age was 22.9 years at the time of death.

Fetal cerebral development causes another difference in symptoms
between men and women.  The greater susceptibility of boys to birth
trauma results in a higher prevalence of certain kinds of cerebral
abnormalities.  These abnormalities can be linked to symptoms which
occur primarily in males.  For example, a cerebral deficiency which
appears more prominently in schizophrenic males is a pathology of the
limbic system.  Reductions in volume of all of the amygdala,
hippocampus, and the entorhinal cortex have been found in post-mortem
studies of schizophrenic patients (Bogerts et al., 1985, cited in
Kopala and Clark, 1990).  These abnormalities are associated with
``negative symptoms'' in men, characterized by a lack of ordinary
emotion (Haas et al., 1990).  In particular, men are somewhat more
likely to have poor psychological history prior to onset of symptoms
and a flat affect.  This part of the brain is also responsible for
olfactory identification.  This has the expected effect: some
olfactory agnosia is found in half of male schizophrenic patients.  No
schizophrenic women were found to have the same problem (Kopala and
Clark, 1990).

Another gender-based effect is that of hormones, especially estrogen,
on schizophrenia.  We have already seen that schizophrenic women tend
to have less severe and less frequent symptoms.  Of course, women also
have higher estrogen levels.  The correlation between lower estrogen
levels and more severe symptoms is not only present in the comparison
of men and women, but can also be observed as estrogen levels change.
Symptoms are attenuated during menstruation, and almost complete
relapse occurs during pregnancy, when estrogen levels are at the
highest.  Conversely, symptoms are worst premenstrually, post partum,
and after menopause, when estrogen levels are lowest.  Indeed,
although women tend to be better off than men, long-term outcomes are
the same in men and women (Seeman and Lang, 1990).

Gender also has some correlation with the effectiveness of different
kinds of treatment.  One approach to treating psychological illness is
to involve the family in the therapy of a patient.  One form of this
kind of therapy is Inpatient Family Intervention, or IFI.  This
therapy involves bringing the family of an inpatient into the
hospital, and identifying how the particular stresses of the family
might be contributing to the patient's symptoms.  The family learns
what are reasonable expectations of their schizophrenic relatives.
The need and benefits of an ongoing course of treatment after
discharge from the hospital are also discussed.  Haas, et al. (1990)
integrated IFI with a normal course of treatment for schizophrenia in
a hospital, and observed how this affected the outcome of treatment in
men and women.  Although there was no change observed in the symptoms
of either gender at discharge, the families of female patients who
underwent IFI therapy exhibited a lower sense of being burdened, less
rejection of the ill relative, and more support of ongoing treatment.
The families of males did not exhibit these behaviors.  This direct
effect is interesting, because it resulted in the indirect effect that
with the additional support of their families, females performed
better after getting out of the hospital than did male counterparts on
IFI or female controls.  While this effect seems to be related to the
generally improved socialization of schizophrenic women, it is notable
that this difference can be amplified by use of therapy.  This point
is different from the others discussed here because there does not
seem to be a direct physiological cause, only a sociological one.

In this paper, we have seen how the nature of schizophrenia differs
between men and women.  Developmental differences due to gender from
early stages of fetal growth to late adolescence have a significant
effect on the entire course of the disease.  These differences affect
the age of onset, the kind of symptoms, the severity of the symptoms,
and the frequency with which they recur.  Although cerebral defects
are difficult to correct, the differences in the effect of hormones
and psychosocial therapy on women seem to point to possible future
research in using pharmacological or theraputic treatments to mimic
these benefits in men.

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\bf\Large References
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Angermeyer, M.C., K\"uhn, L., and Goldstein, J.M., (1990).  Gender and the
Course of Schizophrenia: Differences in Treated Outcomes.  {\em
Schizophrenia Bulletin, Vol. 16, No. 2,} pp. 293-308.

Bogerts, B., Meertz, E., and Schofeldt-Bausch, R., (1985).  Basal
ganglia and limbic septum pathology in schizophrenia.  {\em Archives
of General Psychiatry, Vol. 42,} pp. 784-791.

Flor-Henry, P., (1990).  Influence of Gender in Schizophrenia as
Related to other Psychopathological Syndromes.  {\em Schizophrenia
Bulletin, Vol. 16, No. 2,}, pp. 211-227.

Forrest, A.D., and Hay, A.J., (1971).  Sex differences and the
schizophrenic experience.  {\em Acta Psychiatrica Scandinavica, Vol.
47,} pp. 137-147.

Haas, G.L., Glick, I.D., Clarkin, J.F., Spencer, J.H., and Lewis,
A.B., (1990).  Gender and Schizophrenia Outcome: A Clinical Trial of
an Inpatient Family Intervention.  {\em Schizophrenia Bulletin,
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Kopala, L., and Clark, C., (1990).  Implications of Olfactory Agnosia
for Understanding Sex Differences in Schizophrenia.  {\em
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Loranger, A.W., (1984).  Sex difference in age at onset of
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Majczak, A., Olajossy, M., Nagay, J., and Perzynski, J., (1981).
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McEwen, B.S., (1981).  Neural gonadal steroid actions.  {\em Science,
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Seeman, M.V., and Lang, M., (1990).  The Role of Estrogens in
Schizophrenia Gender Differences.  {\em Schizophrenia Bulletin,
Vol. 16, No. 2,} pp. 185-194.

Sikanartey, T., and Eaton, W.W., (1984).  Prevalence of schizophrenia
in the Labadi district of Ghana.  {\em Acta Psychiatrica Scandinavica,
Vol. 69,} pp. 156-161.

Test, M.A., Burke, S.S., and Wallisch, L.S., (1990).  Gender Differences
of Young Adults With Schizophrenic Disorders in Community Care.  {\em
Schizophrenia Bulletin, Vol. 16, No. 2,} pp. 331-344.

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