Philadelphia College of Osteopathic Medicine DigitalCommons@PCOM PCOM Psychology Dissertations Student Dissertations, Theses and Papers 2009 Sex Differences in Symptom Presentation of Schizotypal Personality Disorder in First-Degree Family Members of Individuals with Schizophrenia Alexandra Duncan-Ramos Philadelphia College of Osteopathic Medicine, [email protected] Follow this and additional works at: http://digitalcommons.pcom.edu/psychology_dissertations Part of the Clinical Psychology Commons Recommended Citation Duncan-Ramos, Alexandra, "Sex Differences in Symptom Presentation of Schizotypal Personality Disorder in First-Degree Family Members of Individuals with Schizophrenia" (2009). PCOM Psychology Dissertations. Paper 40. This Dissertation is brought to you for free and open access by the Student Dissertations, Theses and Papers at DigitalCommons@PCOM. It has been accepted for inclusion in PCOM Psychology Dissertations by an authorized administrator of DigitalCommons@PCOM. For more information, please contact [email protected]. Philadelphia College of Osteopathic Medicine Department of Psychology SEX DIFFERENCES IN SYMPTOM PRESENTATION OF SCHIZOTYPAL PERSONALITY DISORDER IN FIRST-DEGREE FAMILY MEMBERS OF INDIVIDUALS WITH SCHIZOPHRENIA By Alexandra Duncan-Ramos, M.S., M.S. Submitted in Partial Fulfillment of the Requirements of the Degree of Doctor of Psychology July 2009 PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE DEPARTMENT OF PSYCHOLOGY Dissertation Approval This is to certify that the thesis presented to us by Alexandra Duncan-Ramos on the 23rd day of July, 2009 in partial fulfillment of the requirements for the degree of Doctor of Psychology, has been examined and is acceptable in both scholarship and literary quality. Committee Members' Signatures: Barbara Golden, Psy.D., ABPP, Chairperson Brad Rosenfield, Psy.D. Monica E. Calkins, Ph.D. Robert A. DiTomasso, Ph.D., ABPP, Chair, Department of Psychology Sex Differences iii Acknowledgments First and foremost I must give glory and honor to my Lord and Savior, Jesus Christ. For without His presence in my life, I believe my path and career choice would have been very different and successful completion of my graduate training impossible. Second, I would like to thank my husband for his love, support, and unending encouragement. His understanding and unselfish sacrifices enabled me to focus freely on my course work and training requirements. I love you very much, honey. I would also like to thank my family, including my mom, dad, father and two sisters for their continued love, patience, and understanding, as well as for graciously scheduling family time around my busy schedule to allow me to learn and grow personally and professionally. Thank you! To Dr. Raquel Gur and Dr. Monica Calkins, thank you for allowing me the opportunity to fully experience the research process from start to finish. My time with the Brain Behavior Laboratory reaffirmed my servant’s approach to working in mental healthcare. I would also like to acknowledge Dr. Calkins’ generosity in making time within her busy day to kindly spend hours with me, analyzing and helping me to understand my data. And last, I would like to thank each and every faculty member at the Philadelphia College of Osteopathic Medicine from whom I have had the privilege of learning during my years as a student. I specifically want to thank Dr. Barbara Golden for her continued support and encouragement, as well as her guidance throughout my training. Your kindness and patience made the dissertation process, which at times seemed insurmountable, very manageable and reasonable. Thank you! Sex Differences iv Abstract Schizophrenia (SCZ) is a devastating illness, with clinical symptoms generally characterized as positive or negative. The reach of SCZ is broad, significantly impacting economic, social and familial facets of life. Current literature suggested optimal treatment for individuals with SCZ must include medication management and family psychological interventions to achieve patient stabilization. Literature has identified a likely familial and genetic link between individuals with SCZ and schizotypal personality disorder (STPD) in first-degree family members (FDFM), and has proposed a similar sex distinction with regard to symptomatology in STPD often noted in SCZ. The results of this investigation yielded clinically significant information; however, none of the study hypotheses was supported. Sex differences were not observed between relatives, compared with healthy comparison participants: male parents compared with female parents, and siblings compared with comparison subjects. A noteworthy finding was that relatives, including siblings, were found to endorse more symptoms significantly consistent with STPD when compared with healthy comparison subjects in all analyses. Implications for training and treatment were discussed. Limitations of the study and directions for future research were also addressed. Sex Differences v Table of Contents Acknowledgments iii Abstract iv List of Figures x List of Tables xi Epigraph xiii Chapter One: Statement of the Problem 1 Overview of the Problem 1 Purpose of the Study 2 Relevance to Psychological Treatment 3 Chapter Two: Literature Review 5 Impact of Schizophrenia 6 Economic Impact 6 Social Impact 8 Familial Impact 10 Attributional Model of Emotion 11 Expressed Emotion in Families 13 Role of Family Stress 15 Cultural Influence 18 Summary of Schizophrenia Impact 20 Treatment Strategies 20 Family Therapy 22 Sex Differences vi Group Family Therapy 26 Individual Therapy 27 Concluding Statement on Treatment 31 Overview of STPD 31 Description of STPD Clinical Presentation 32 Symptom Clustering of STPD 34 Diagnostic Assessments 35 Self-Report Inventories 36 Semi-Structured Interviews 37 Benefits and Limitations of Assessment Inventories 39 Examination of STPD Research 40 Clinical Tradition 41 Familial Tradition 43 Adoptive Studies 44 Family Studies 50 Twin Studies 52 Research Examining Sex Differences 55 Sex Differences in SCZ 55 Sex Differences in STPD 56 Chapter Three: Hypotheses 59 Chapter Four: Methods 62 Methodology Overview 62 Sex Differences vii Design and Design Justification 62 Overview of Genetic Family Studies 63 Genetic Studies Procedures 65 Measures of Genetic Studies 66 Present Investigation 67 Participants 67 Procedures 68 Investigation Measure 69 Structured Interview for Schizotypy 69 Modified Structured Interview for Schizotypy 70 Chapter Five: Results 77 Overview of Analyses 77 Preliminary Analyses 77 Sample Refinement 78 Interview Reliability and Validity 80 SIS Scoring and Analyses of SIS Responses 81 Conservative Sample Demographics 82 Preliminary Analyses Summary 83 Data Analyses 84 Conservative Sample Analyses 84 First Hypothesis Analysis 84 Second Hypothesis Analysis 86 Sex Differences viii Third Hypothesis Analysis 86 Inclusive Sample Analyses 88 First Hypothesis Analysis 88 Second and Third Hypothesis Analyses 89 Summary of Data Analyses 90 Chapter Six: Discussion 91 Overview of Findings 91 Genetic Implications 92 Treatment Implications 93 Overcoming Treatment Barriers 96 Individual and Familial Level 96 Training and Supervision Level 98 Administrator and Management Level 101 Mental Health-System Level 102 Treatment Barrier Summary 103 Clinical Application 103 Proposed Mental Health Program 105 Limitations of the Study 108 Future Research 110 References 112 Appendix 134 Tables 139 Sex Differences ix Figure Captions 155 Figures 156 Sex Differences x List of Figures Figure 1. Inclusive Sample SIS Subscale Means and Diagnostic Categorization 156 Figure 2. Conservative Sample SIS Subscale Means and Diagnostic Categorization 157 Figure 3. Conservative Sample Effect Sizes Between Total Male and Female Participants 158 Figure 4. Conservative Sample Effect Sizes Between Relatives and Comparison Participants 159 Figure 5. Conservative Sample Effect Sizes Between Siblings and Comparison Participants 160 Figure 6. Inclusive Sample Effect Sizes Between Relative and Comparison Participants 161 Figure 7. Inclusive Sample Effect Sizes Between Total Male and Female 162 Figure 8. Inclusive Sample Effect Sizes Between Sibling and Comparison Participants 163 Sex Differences xi List of Tables Table 1. Inclusive Sample Demographics (n = 324) 139 Table 2. Inclusive Sample Diagnostic Characteristics (n = 324) 140 Table 3. Inclusive Participant Reaction to Interview Length (n = 324) 141 Table 4. Inclusive Participant Openness to Questions (n = 324) 142 Table 5. Inclusive Participant Understanding of Interview (n = 324) 143 Table 6. Inclusive Participant Overall Quality of Interview (n = 324) 144 Table 7. STPD Diagnostic Criteria Categorization 145 Table 8. Conservative Sample Demographics (n = 246) 146 Table 9. Conservative Sample Diagnostic Characteristics (n = 246) 147 Table 10. Results Overview 148 Table 11. Conservative Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Between Relatives and CCS 149 Table 12. Conservative Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Between Parents 150 Table 13. Conservative Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Between Siblings and CCS 151 Table 14. Inclusive Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Between Relatives and CCS 152 Table 15. Inclusive Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Between Parents 153 Table 16. Inclusive Sample SIS Subscales Pairwise Cohen’s d Effect Sizes Sex Differences xii Between Siblings and CCS 154 Sex Differences xiii Epigraph I have set the Lord always before