As it is known, schizophrenia is a complex clinical chronic threat to individuals’ physical and cognitive well-being, causing damage to health. Schizophrenia is one of the most studied pathological conditions in which the splitting of the patient’s consciousness and thought processes is evident. Despite the general study of this neurodegenerative condition, schizophrenia is ambiguous and manifests differently in different demographic groups. For example, there is ample evidence of differences in the manifestation of schizophrenic disorders for adolescents and the elderly. In addition, despite the development of modern medicine and accurate clinical analysis, there is still no single theory of the origin of this disease. For example, the development of schizophrenia may be related to neurotransmitter disorders, genetic abnormalities, or serious stressors that the individual has experienced (Sallis et al., 2020).
In particular, for example, although early hypotheses originated schizophrenia as a consequence of dopaminergic hyperactivity of brain tissue, the additional effects of other neurotransmitters — such as serotonin or glutamine — are expected to initiate the development of the schizophrenic disorder, are now actively discussed. However, although there is still no prevailing theory on the development of schizophrenia, the academic community is led to believe that the presence of genetic patterns is evident: if one relative in a family has schizophrenia, then it is most likely that someone in the given lineage will have a predisposition.
About schizophrenia, it is fair to recognize that this cognitive pathology often manifests itself in adolescence, which means that young patients are most likely to be diagnosed with it. Meanwhile, with regard to the development of schizophrenia, it is fair to point out that there are differences in gender characteristics. This paper critically evaluates this claim through the use of relevant scientific literature. Ultimately, the work allows us to assess the veracity of the hypothesis of differences in the development of schizophrenia for young women and men.
A Brief Background on Schizophrenia
It is fair to note that by now, there is no consensus on what precisely the condition schizophrenia is and how it can be interpreted. For example, the WHO interprets this fundamental pathophysiology as a type of psychomental disorder and psychosis in which there is a distortion of the individual’s thinking, consciousness, and emotional activities (Schizophrenia, 2019). In older sources, authors have tended to identify schizophrenia with dementia and insanity (Gottesman et al., 1982).
In the absence of remission, the patient experiences hallucinations, deviant behavior, disorganized speech, and impaired emotions. In addition, the WHO continues, schizophrenia is not one of the most common mental illnesses of humanity, yet it affects 20 million people worldwide. The peculiarities of the course of this disease lead to the fact that sick patients have a higher probability — usually two to three times higher — of dying earlier (Schizophrenia, 2019). Based on the above, it is clear that schizophrenia brings social severe, communication, and work limitations to an individual’s life.
Gender Differences in the Development of Schizophrenia
Despite the fact that the pathology of the schizophrenic disorder still requires careful study, one of the facts already known is that schizophrenia has a gender dimorphism. In general, it is worth saying that contrary to social trends to equate the social and economic functional roles of men and women, the differences between genders have a neurobiological basis.
This means that different factors in the epidemiology of the disease, be it the time of onset, the course of the disease, the severity of symptomatic manifestations, the characteristics of the perception of this condition, and the response to therapeutic treatment, are different for women and men, especially at an early age. In this context, it is particularly important to emphasize that the young age of patients is a unique feature of schizophrenic disorders since it is at a young age that there is an increased incidence of the disease. This section reviews key gender differences in the development and course of schizophrenia in women and men if discussed in the academic community.
It is scientifically recognized that there are some defense mechanisms for the female body against the development of schizophrenic disorders that are absent in men. In more detail, this has to do with the number of estrogen hormones that make up the classic female sex pattern. Estrogen is commonly thought of as the collective name for a class of female steroid sex hormones originating in the follicular apparatus of the ovaries. In other words, estrogens are the essential steroid hormones responsible for sexual development, reproductive function, bone system, disease resistance, and overall health in women (Hammes & Levin, 2019).
Research makes it clear that estrogen levels in women are important predictors of resistance and susceptibility to schizophrenia, which has given rise to the estrogen defense against psychosis theory. It is known that the level of steroidal female hormones is inconsistent and depends directly on the stage of a woman’s life. For example, during the postpartum period, estrogen levels decrease significantly, whereas, during pregnancy, these levels are elevated (Kettunen et al., 2021).
Regarding menstrual cycles, estrogen hormone concentrations increase significantly during the first days of premenstrual syndrome, with the hormone reaching a quantitative peak on the first day of ovulation. In addition, for young girls at the age of early puberty (11-14 years old), estrogen levels increase dramatically during the menarche phase, a woman’s first menstrual bleeding. By studying these patterns, researchers have concluded that the severity of schizophrenic psychoses is related to the amount of estrogen in the blood. When hormone concentrations decrease, the most severe psychophysiological conditions occur for the woman, at which time psychosis reaches its peak. On the contrary, during times of increased estrogen — pregnancy and luteal phase — the severity of menstrual psychosis naturally decreases. It is during these periods that women experience favorable improvements in their psychological state and less pronounced neurocognitive deficits.
As is evident, estrogen defense is an important predictor of the development of the schizophrenic state or, at any rate, the manifestation of relapses and remissions. Although it is erroneous to focus only on the role of a single family of hormones in the development of schizophrenia, it is impossible to exclude the importance of estrogen as a mechanism of internal regulation of schizophrenia.
That said, it is clear that there should be much fewer estrogens in the normal male body. Thus, in a male organism, estrogens, of which estradiol forms the basis, are involved in the fine regulation of prostate and testicular functions, as well as in the processes of lipid and mineral metabolism. In the absence of possibilities of premenstrual syndrome, menstrual cycle, and pregnancy, it is correct to conclude that men are not characterized by estrogen protection.
Another important gender difference in the development of schizophrenic conditions is epidemiological patterns. This includes the entire set of characteristics that qualitatively and quantitatively answer questions about the nature of the differences. For example, one of the most obvious differences, widely discussed in the literature, is incidence. Men are thought to be diagnosed more frequently than women, with a correlation coefficient of 1.42 (Ochoa et al., 2012).
This means that men have this pathology about 1.5 times more often than women, which means it is reasonable to assume, and subsequently discuss, that there are some mechanisms for men that determine a higher predisposition. It is noteworthy that a higher incidence does not mean a higher prevalence since, for men and women, the frequency of occurrence of this pathology is equal on average. One potential reason for this discrepancy is the higher proportion of suicides among men with the diagnosis: some male patients do not survive to hospitalization and thus do not contribute to the epidemiological statistics. In addition, another criterion emphasizing the gender difference in the development of schizophrenia is the age of onset. It is known that for men, the average age of diagnosis is 18-25, whereas, for women, the age is 25-35 (Ochoa et al., 2012).
The data also show that the distribution curves for younger patients are not isomorphic: for example, there are two sharp peaks of diagnosis for female patients. This means that immediately after menarche and reaching the age of 40, the number of female patients with schizophrenia increases dramatically. Not all studies, however, agree with exactly these results. Li et al. (2016) showed — as displayed in Figure 1 — that for men, the peak age of schizophrenic diagnoses is 20-24 years, whereas for women, two peaks are also noticeable, but instead of menarche, the first peak is characteristic of 25-29 years. In other words, for female patients, the presence of two peaks is confirmed, but one of them is shifted to the right.
In addition, a more detailed analysis of Figure 1 also shows that for men, the earlier appearance of the first signs of schizophrenia is noticeably earlier than for women. Similar findings hold true for the number of hospitalizations. Evidence shows that the number of hospitalizations and their duration was, on average, lower for women than for men (Ochoa et al., 2012). One possible reason could be that men’s access to clinical services may be generally higher than women’s, but it is more likely that the actual reasons are not yet fully understood.
Differences have also been observed in patterns of symptomatic manifestations of the illness, whether in the severity of schizophrenic signs or in their quantification. Some of the earlier authors have argued that men are characterized by greater symptom severity, including the presence of more negative symptoms compared to women (Ochoa et al., 2012). This includes complications related to the individual’s social activity: male patients tend to be more withdrawn and restricted in communication than women. In contrast, female patients predominantly suffer from mood swings and affective states that resemble the signs of clinical depression.
It is necessary to revisit the fact that schizophrenia is primarily a neurocognitive condition in order to discuss the difference in cognitive distortions resulting from the deleterious effects of schizophrenia. For instance, male patients are known to have more severe and severe cognitive distortions than females: this applies to short-term and long-term memory algorithms (Li et al., 2016). It is also known that cognitive dysfunctions such as loss of attention and concentration, visual perception, and language skills are more common in women.
Gender Differences in Clinical Therapy
Modern medicine does not offer significant differences in the treatment of schizophrenic spectrum disorders for men and women but instead creates universal therapies tailored to a specific medical history. It is important that the premorbid condition was generally severe among men, yet a larger proportion of women (59%) than men (50%) used antidepressants prior to clinical therapy, although men began taking them more frequently, again consistent with data from Figure 1 (Ochoa et al., 2012; Sommer et al., 2020). Notably, the mean age of initiation of therapy was equal for both sexes and was generally quite high, thirty years, which may indicate late detection of symptoms in patients.
Medication treatment for schizophrenic psychosis differed slightly for women and men. Gender-specific treatment is thought to produce better results with fewer side effects, which in turn has public health benefits. Men have been shown to use olanzapine and clozapine most frequently, while women have been prescribed quetiapine and aripiprazole (Sommer et al., 2020). The structural difference is that medications for women are mostly used in short-term therapy and have fewer side effects related to weight gain and body lipid profile than medications for men (Jinda et al., 2013). In addition, male patients are thought to traditionally require higher doses of medications (Li et al., 2016).
This, in turn, agrees well with the evidence of longer hospitalization times for men compared to women. Neuroleptic medications prescribed to women have more side effects in terms of endocrine effects: hyperprolactinemia, autoimmune conditions, and hypotension (Li et al., 2016). In general, it is worth saying that although drug regimens differ slightly, no significant differences in response to therapy have been found for women and men. Typical neuroleptics achieve remission and reduce symptom severity in all genders. Among others, it is noteworthy to note that remissions are generally more frequent in female patients, whereas relapses are mostly characteristic of men.
Social Perception of the Disease
Within social functioning, there is a marked difference between women and men, the result of many years of research. Social adjustment for women with schizophrenia is easier and more accessible than for men (Ochoa et al., 2912). Male patients tend to lead more independent and isolated lifestyles than female patients, and in addition, have a greater predilection for substance use. Male patients have been shown to be more likely to use alcohol and drugs than women, which is an additional predictor of worse socialization for men (Dragoi & Vladuti, 2020). Given the data from Figure 1, the socialization of girls and young women with similar frequencies of diagnosis to men appears to proceed more easily as far as educational patients are concerned. In addition, women both during treatment and in remission appear to be more stress-resistant and emotionally stable than men.
One longstanding study shows that the key social needs of male patients with schizophrenia were domestic (real estate, education, food), whereas, for women, the critical needs were awareness of community services (Ochoa et al., 2012). This may imply that women are more likely to lead a social life compared to men, whose needs are more self-focused. From this, one can conclude that male patients have difficulty socializing in schools and at work because of impaired cognitive functioning, social skills, and less stress tolerance.
To summarize, schizophrenia is an extremely popular and culturally prevalent condition that is not well understood by the academic community. Schizophrenia is not a severe epidemiological problem in communities, and as has been said, no more than twenty million people worldwide suffer from this pathology. Nevertheless, given the neurodegenerative nature of schizophrenia, it is right to conclude that this disease requires serious studies and in-depth research. To date, no unified theory has yet been proposed to explain the origin of this disease, and similar inconsistencies and discrepancies are characteristic of the epidemiological features of schizophrenia.
In the present work, it has been shown that sexual dimorphism is characteristic of the disease, but discussion of specific differences is always accompanied by clarification of their non-absoluteness. The results thus obtained years ago may not be confirmed by more recent studies. Overall, in summarizing the whole work, it is worth saying that there are important differences between men and women as patients on all of the points described, and it is unacceptable to state unequivocally that one of the genders is more easily affected by the disease. Ultimately, gender differences must continue to be explored by the academic community in order to create gender-oriented therapies and practices for patient recovery after treatment and in remission, thereby improving overall clinical effectiveness.
Dragoi, A. M., & Vladuti, A. (2020). The comorbidity between schizophrenia and alcohol. Substance addiction and alcohol use link to schizophrenia. Journal of Educational Sciences & Psychology, 10(1), 141-148.
Gottesman, I. I., Shields, J., & Hanson, D. R. (1982). Schizophrenia. CUP Archive.
Hammes, S. R., & Levin, E. R. (2019). Impact of estrogens in males and androgens in females. The Journal of Clinical Investigation, 129(5), 1818-1826.
Jindal, K. C., Singh, G. P., & Munjal, V. (2013). Aripiprazole versus olanzapine in the treatment of schizophrenia: A clinical study from India. International Journal of Psychiatry in Clinical Practice, 17(1), 21-29.
Kettunen, P., Koistinen, E., Hintikka, J., & Perheentupa, A. (2021). Oestrogen therapy for postpartum depression: efficacy and adverse effects. A double-blind, randomized, placebo-controlled pilot study. Nordic Journal of Psychiatry, 1-10.
Li, R., Ma, X., Wang, G., Yang, J., & Wang, C. (2016). Why sex differences in schizophrenia? Journal of Translational Neuroscience, 1(1), 37-42.
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, 1-9.
Sallis, H. M., Croft, J., Havdahl, A., Jones, H. J., Dunn, E. C., Smith, G. D.,… & Munafò, M. R. (2020). Genetic liability to schizophrenia is associated with exposure to traumatic events in childhood. Psychological Medicine, 51, 1814-1821.
Schizophrenia. (2019). WHO. Web.
Sommer, I. E., Tiihonen, J., van Mourik, A., Tanskanen, A., & Taipale, H. (2020). The clinical course of schizophrenia in women and men—a nation-wide cohort study. NPJ Schizophrenia, 6(1), 1-7.