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Gender Differences in the Experience of Psychosis

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Gender Differences in the Experience of Psychosis GENDER DIFFERENCES IN THE EXPERIENCE OF PSYCHOSIS Amy Jones A thesis submitted in partial fulfilment of the requirements of the University of East London for the degree of Professional Doctorate in Clinical Psychology May 2018 ABSTRACT Background Gender differences in the presentation and course of psychosis are well documented. However, there is a lack of research which examines gender differences in the subjective experience of psychosis at a content level. Aims This study aims to explore gender differences in the presentation and the thematic content of psychotic symptoms. In order to contextualise the research findings, the study will also explore additional demographic and causal factors that might explain any gender differences in presentation, including history of substance use and history of abuse. Method The electronic medical records of 160 users of Early Intervention for Psychosis Services were comprehensively reviewed. Clinician reports were used to collect quantitative and qualitative data pertaining to symptom presentation. A quantitative analysis of symptom presentation was conducted and a thematic analysis was used to explore themes in the content of psychotic symptoms. Results Men experienced a greater number of psychotic symptoms in total, as well as more delusions, negative symptoms and symptoms of thought disorder. Specifically, they were more likely to experience grandiose delusions, hostility, pressure of speech, thought withdrawal and avolition. Women experienced a greater number of hallucinations and were more likely to experience tactile hallucinations. Thematic analysis revealed that men were more likely to experience themes of being attacked or possessing extraordinary powers. Women were more likely to experience themes of people not being who they seem, hearing noises and the feeling of being touched. Further analyses suggested that gender differences in life experience, namely substance use and sexual abuse, may partially explain gender differences in psychotic symptoms and content. i Conclusion Gender differences exist at both symptom and content levels. Psychotic experiences may be influenced by life experiences and sociocultural expectations of gender. Mental health services should attend to the meaning and content of psychotic symptoms, and to gender differences in the experience of psychosis. ii ACKNOWLEDGEMENTS I would like to thank my supervisor, Professor John Read, whose passion, expertise and calm, encouraging manner have been invaluable. I am grateful to Dr Matthew Jones-Chesters and my grandfather, Derek Butler, for their statistical advice, and owe a special thanks to Dr Lisa Wood whose practical support made data collection as smooth a process as I could have hoped. I would also like to thank my parents for their constant interest, encouragement and support, as well as their close attention to detail when proof reading, a task that I am grateful to Liz Naylor for sharing in too. Finally, thank you to James Briggs for believing in me and for supporting me throughout every step of this process. iii CONTENTS 1. INTRODUCTION ………………………………………………. 1 1.1. Overview ………………………………………………………. 1 1.2. Note on terminology ………………………………………… 1 1.3. Psychosis and ‘schizophrenia’ ……………………………. 1 1.3.1. Reliability and validity of ‘schizophrenia’ ……………………. 1 1.3.2. Causal explanations of ‘psychosis’ and ‘schizophrenia’ ….. 3 1.3.2.1. Biological explanations ……………………………………….. 3 1.3.2.2. Epigenetics …………………………………………………….. 4 1.3.2.3. Psychological processes ……………………………………… 4 1.3.2.4. Adverse life events ……………………………………………. 5 1.3.2.5. Childhood adversity …………………………………………… 6 1.3.2.6. Substance use ………………………………………………… 8 1.3.2.7. Biopsychosocial explanations ……………………………….. 9 1.3.3. Mainstream services for psychosis and ‘schizophrenia’ ….. 9 1.3.3.1. Antipsychotic medication ……………………………………... 10 1.3.3.2. Cognitive Behavioural Therapy ……………………………… 10 1.3.3.3. Family Intervention ……………………………………………. 11 1.3.3.4. Third Wave Therapies ………………………………………… 11 1.3.3.5. Early Intervention in Psychosis Services …………………… 12 1.3.3.6. Open Dialogue ………………………………………………… 13 1.3.3.7. Hearing Voices Movement …………………………………… 13 1.4. Literature Review: Gender differences in psychosis …. 13 1.4.1. Terminology …………………………………………………… 13 1.4.2. Literature search strategy ……………………………………. 14 1.4.3. Prevalence …………………………………………………….. 15 1.4.4. Age of onset …………………………………………………… 15 1.4.5. Duration of untreated psychosis (DUP) ……………………... 16 1.4.6. Diagnosis ……………………………………………………….. 16 1.4.7. Cognitive functioning ………………………………………….. 16 1.4.8. Social functioning ……………………………………………… 17 1.4.9. Course and outcome ………………………………………….. 18 1.4.10. Medication use and response ………………………………... 19 1.4.11. Engagement with services …………………………………… 19 iv 1.4.12. Symptom presentation ………………………………………... 20 1.4.12.1. Positive and negative symptom differences ………………... 20 1.4.12.2. Differences in types of positive symptoms …………………. 21 1.4.13. Content of psychotic experiences …………………………… 21 1.14.3.1. Gender differences in delusional themes …………………… 22 1.14.3.2. Gender differences in themes of hallucinations ……………. 24 1.5. Explanations of gender differences ……………………… 24 1.5.1. Abuse and psychosis …………………………………………. 24 1.5.1.1. Gender differences in prevalence of abuse ………………… 24 1.5.1.2. Specific abuse leading to specific symptoms ………………. 25 1.5.1.3. Autobiographical content of psychosis ……………………… 26 1.5.2. Substance use and psychosis ………………………………. 28 1.5.2.1. Gender differences in substance use ………………………. 28 1.5.2.2. Relationship between substance use and adverse life experiences ……………………………………………………. 28 1.5.3. Gender roles …………………………………………………… 29 1.6. Research and clinical implications ……………………….. 30 1.7. Aims of current study ……………………………………….. 31 2. METHOD ……………………………………………………….. 32 2.1. Overview ………………………………………………………. 32 2.2. Ethical issues …………………………………………………. 32 2.2.1. Ethical approval ……………………………………………….. 32 2.2.2. The Clinical Record Interactive Search System …………… 32 2.2.3. Confidentiality of data ………………………………………… 32 2.2.4. Consent ………………………………………………………… 33 2.3. Epistemological position …………………………………… 33 2.4. Design …………………………………………………………. 34 2.5. Participants …………………………………………………… 34 2.5.1. Inclusion and exclusion criteria ……………………………… 35 2.6. Materials ………………………………………………………. 35 2.7. Procedure …………………………………………………….. 36 2.7.1. Inter-rater reliability …………………………………………… 37 2.8. Approach to analysis ……………………………………….. 38 2.8.1. Statistical analysis …………………………………………….. 38 v 2.8.2 Thematic analysis ……………………………………………... 39 2.8.2.1. Data collection …………………………………………………. 40 2.8.2.2. Phase one: Familiarisation with the data …………………… 40 2.8.2.3. Phase two: Coding ……………………………………………. 40 2.8.2.4. Phase three: Searching for themes …………………………. 40 2.8.2.5. Phase four: Reviewing themes ………………………………. 41 2.8.2.6. Phase five: Defining and naming themes …………………... 41 2.8.2.7. Inter-rater reliability ……………………………………………. 41 2.8.3. Statistical analysis of gender differences in themes ………. 42 3. RESULTS ……………………………………………………… 43 3.1. Overview ………………………………………………………. 43 3.2. Participant characteristics …………………………………. 43 3.3. Research question: Do men and women experience different types of psychotic symptoms? ………………… 45 3.3.1. Gender differences in number of symptoms ……………….. 45 3.3.2. Gender differences in specific types of symptoms ………… 47 3.4. Research question: Do demographic factors, including a history of abuse and substance use, account for any differences in presentation between men and women? 50 3.4.1. Gender differences in histories……………………………….. 50 3.4.2. Gender differences in relationship between histories and symptoms ………………………………………………………. 51 3.4.2.1. Relationships that held for both genders …………………… 53 3.4.2.2. Relationships that held for men but not women ……………. 53 3.4.2.3. Relationships that held for women but not men ……………. 54 3.5. Research question: Does the content of psychotic experiences differ for men and women? ………………… 54 3.5.1. Themes and sub-themes of psychotic symptoms …………. 54 3.5.2. Themes more common for men ………..………..…………... 58 3.5.2.1. Special powers or abilities ……………………………………. 58 3.5.2.2. Being harmed, attacked or killed (non-specific) ……………. 59 3.5.3. Themes more common for women………..………..………... 59 3.5.3.1. Pregnancy ………..………..………..………..……….……….. 59 3.5.3.2. Tactile hallucinations ………..………..………..………..……. 60 vi 3.5.3.3. Tactile hallucination of being touched ………..……….…….. 60 3.5.3.4. People are not who they seem ………..………..…………… 60 3.5.3.5. Hearing noises ………..………..………..………..………….. 60 3.5.4. Non-significant trends ………..………………………………. 61 4. DISCUSSION…………………………………………………… 62 4.1. Overview ………………………………………………………. 62 4.2. Study aims …………………………………………………….. 62 4.3. Sample characteristics ……………………………………… 62 4.4. Research question: Do men and women present with different psychotic symptoms? …………………………… 63 4.4.1. Total symptoms ………..………..………..………..………….. 63 4.4.2. Delusions ………..………..………..………..………..……….. 64 4.4.3. Hallucinations ………..………..………..…..………..……….. 64 4.4.4. Thought disorder ………..………..………..………..………… 65 4.4.5. Negative symptoms ………..………..………..……..……….. 65 4.5. Research question: Does the content of psychotic experiences differ for men and women? ………………… 66 4.5.1. Content of psychotic experiences in men ………..…………. 67 4.5.1.1. Being attacked, harmed or killed ………..………..………….. 67 4.5.1.2. Special powers or abilities ………..………..………..……….. 67 4.5.1.3. Everything is a movie/ game/ simulation…………..………… 68 4.5.1.4. Unfaithfulness ………..……………………..………..………... 70 4.5.1.5. Voices
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