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Gender differences in delusional disorder: Evidence from an outpatient sample
Psychiatry Research 177 (2010) 235–239
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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p s y c h r e s
Gender differences in delusional disorder: Evidence from an outpatient sample Enrique de Portugal a, Nieves González b, Vilaplana, Miriam b, Josep M. Haro b,c, Judit Usall b,c, Jorge A. Cervilla d,e,⁎ a
Department of Psychiatry, Hospital Gregorio Marañon, Madrid, Spain Research and Development Unit, Sant Joan de Déu-SSM, Barcelona, Spain CIBER en Salud Mental (CIBERSAM) nodo de Sant Joan de Déu, Barcelona, Spain d Department of Psychiatry and Institute of Neurosciences, University of Granada, Spain e CIBER en Salud Mental (CIBERSAM) nodo de la Universidad de Granada, Spain b c
a r t i c l e
i n f o
Article history: Received 27 May 2009 Received in revised form 21 November 2009 Accepted 22 February 2010 Keywords: Delusial disorder Gender Paranoia Psychosis
a b s t r a c t Our objective was to study gender differences in delusional disorder (DD), by comparing potential risk factors, clinical correlates, illness course characteristics, and functionality. The sample was composed of 86 outpatients with DD (according to the SCID-I for DSM-IV criteria). The following assessment instruments were used service use and demographic questionnaires, Standardized Assessment of Personality (SAP), the Positive and Negative Symptom Scale (PANSS), Montgomery–Asberg Depression Rating Scale (MADRS), Mini-Mental State Examination (MMSE), Mini International Neuropsychiatry Interview (MINI), Sheehan Disability Inventory (SDI), and the Global Assessment of Functioning (GAF) scale. The female-to-male ratio was 1.6:1. Men were more likely to be single, while women were more likely to be widows. Men had a greater frequency of schizoid and schizotypal premorbid personality disorders and of premorbid substance abuse. There were no differences for other risk factors (immigration, deafness, late onset, other personality disorders, and family history). Men were younger at onset and more frequently had acute onset of the disorder. Men had more severe symptoms (higher score on the global or separate PANSS scales). There were no gender differences for the remaining symptomatological variables (types of DD, presence and severity of depression, presence of hallucinations, severity of global cognitive functioning and presence of axis I comorbidity). Global and partial (work, family, and social) functioning was significantly poorer among men. Course type and consumption of resources appeared to be similar. We conclude that men with DD had significantly more severe symptoms and worse functionality. They also had a higher frequency of schizoid and schizotypal premorbid personality disorders and premorbid substance abuse. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Unlike gender differences in schizophrenia and affective disorders, the existence of gender differences in delusional disorder (DD, previously known as clinical paranoia) has been poorly studied. As DD has been described primarily according to a male prototype, the diagnosis of DD in women may differ from that of the male prototype (Rudden et al., 1983). The few existing empirical studies in DD are based on small samples, use different diagnostic criteria, are usually poorly designed, and rarely compare clinical differences between both sexes. To the best of our knowledge, there are only two specific studies on gender differences in DD. Rudden's methodologically limited study retrospectively evaluated the clinical differences between 44 females and 44 males diagnosed with DSM-III criteria (Rudden et al., 1983), whereas Bada's well-designed observational study used DSM-IV criteria, ⁎ Corresponding author. CIBERSAM, Section of Psychiatry and Institute of Neurosciences, University of Granada, Spain. Tel.: +34 958 242017. E-mail address: [email protected] (J.A. Cervilla). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.02.017
although the sample size is small (N = 35) (Bada et al., 2000). Prevalence rates are higher in women. Thus, Kendler's (1982) metaanalysis found that female patients slightly outnumbered male patients (the female-to-male ratio was 1.2:1) (Kendler, 1982). Later, smaller studies on DD found an even higher female-to-male ratio (ranging from 1.9:1 to 3:1) (Marino et al., 1993; Yamada et al., 1998; Bada et al., 2000; Maina et al., 2001). Onset occurs at an earlier age in men (Munro, 1991; Marino et al., 1993; Yamada et al., 1998; Hsiao et al., 1999). Men are also more frequently single, whereas female subjects were more frequently widowed (Marino et al., 1993; Munro and Mok, 1995), although other studies did not find any differences in terms of marital status, socioeconomic or educational status (Rudden et al., 1983; Bada et al., 2000). There are even scarcer evidence for gender differences regarding potential risk factors for DD, including late age at onset, low socioeconomic status, social isolation, immigration, sensory deficits, personality, and family transmission (Manschreck, 1996). Nonetheless, presence of interpersonal precipitating factors and late age at onset was found more frequent in females (Rudden et al., 1983; Munro, 1998). In
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addition, the role of subtle organic factors, such as premorbid head trauma with loss of consciousness and premorbid substance abuse may also be important in triggering the onset of DD, particularly among men (Munro and Mok, 1995). Few and controversial gender differences in the clinical characteristics of DD have also been described. According to DSM-III criteria, Rudden et al. (1983) found a greater preponderance of erotomaniac delusions among women, whereas most recent studies using criteria from DSM-III-R (does not include mixed type) and DSM-IV found no gender differences between the different types of DD (Yamada et al., 1998; Hsiao et al., 1999; Bada et al., 2000; de Portugal et al., 2008). Bada et al. (2000) did not find significant gender differences in the severity of delusions using the Brown Assessment of Beliefs Scale (BABS). There are no studies assessing gender differences in positive and negative psychotic psychopathology using standardized instruments. Rudden et al. (1983) found a greater severity of affective symptoms in women and considered that symptomatic expression of DD is more similar to schizoaffective disorder among women. A recent study also found no differences in frequency of depressive disorders (Grover et al., 2007). Further, Bada et al. (2000) found no significant differences in depression severity, although they did found greater comorbidity of depressive disorders among women, as did other authors (Marino et al., 1993; Maina et al., 2001). It is striking that no studies so far have used standardized instruments to assess global cognitive functioning in DD between the genders. Finally, there are few reports of gender differences in the course of DD. While some studies found that men consult a psychiatrist earlier after the onset (Kendler, 1982; Jorgensen and Jorgensen, 1985; Yamada et al., 1998), others found no significant differences (Hsiao et al., 1999; Bada et al., 2000). Bada et al. (2000) found no gender differences in the form of onset (acute or insidious), type of course (phasic or chronic), or degree of social and labour functionality. This paucity of empirical and systematic descriptive studies provides us with a unique opportunity to explore and describe gender differences in DD using a relatively large, thoroughly studied sample. Our three main objectives were: (1) to explore gender differences in the risk factors for DD in the absence of previous studies; (2) to examine symptomatological differences between men and women, since previous results are contradictory; and (3) to determine social functioning by means of scales, with the hypothesis that women function better. 2. Methods 2.1. Sample A cross-sectional sample of 106 individuals with a diagnosis of DD was selected randomly from a computerized case register of five Community Mental Health Centers (CMHC) belonging to Sant Joan de Déu-Mental Health Services (SJD-MHS) in Barcelona (Spain), as described elsewhere (de Portugal et al., 2008). Inclusion criteria were: (a) primary diagnosis of DD (DSM-IV) (American Psychiatric Association, 1994), (b) more than 18 years of age, (c) to live in the catchment areas of the participating CMHC, (d) to at least have received one outpatient visit during the 6 months previous to the beginning of the study, (e) reference psychiatrist's approval to participate in the study, and (f) patient's agreement to participate. Exclusion criteria were: (a) diagnosis of mental retardation; and (b) unfulfillment of the diagnostic confirmation of TD using the Structured Clinical Interview for DSM-IV Axis I Disorders (psychosis module) (Gómez Beneyto, 1995; First et al., 1997). Six patients refused to participate in the study, and in eight patients the reference psychiatrist did not approve their participation in the study and in six patients the diagnosis of DD was not confirmed according to the SCID-I (three fulfilled criteria for the schizophrenia, one for the schizoaffective disorder, one for the psychotic disorder due to medical disease and another one for the psychotic disorder due to substance abuse). Eighty-six patients finished the evaluation, constituting in this way the final sample of our study. All the patients were provided with a complete description of the study and gave their written informed consent to participate after they had been invited to do so by a letter from their psychiatrist. The study was approved by the local research ethics committee. 2.2. Variables and measurements All patients were evaluated by a postgraduate psychology student trained to use all the study instruments. The diagnosis of DD was validated using the psychosis module of the Structured Clinical Interview for DSM-IV axis I disorder, clinical version (SCID-I CV) (Gómez Beneyto, 1995; First et al., 1997). Patients were assigned to one of seven
DSM-IV DD types (persecutory, jealous, somatic, erotomaniac, grandiose, mixed, and unspecified). The Standardized Assessment of Personality (SAP) (Mann et al., 1981) was used to assess premorbid personality. Psychotic psychopathology was assessed using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) (Kay et al., 1987; Peralta and Cuesta, 1994) and history of psychotic psychopathology was examined using Module B (psychotic and associated symptoms) of the SCID-I CV (Gómez Beneyto, 1995; First et al., 1997). The presence and severity of depressive symptoms were assessed using the Montgomery–Asberg Depression Rating Scale (MADRS) (Montgomery and Asberg, 1979; Martínez et al., 1991). Global cognitive functioning was evaluated with the Mini-Mental State Examination (MMSE) (Folstein et al., 1975; Lobo et al., 1999). Coexisting DSM-IV axis I psychiatric disorders were diagnosed using the Mini International Neuropsychiatric Interview (MINI) for DSM-IV (Sheehan et al., 1997; Bobes et al., 1997; Sheehan et al., 1998). Global functioning was assessed using the Global Assessment of Functioning (GAF) scale (American Psychiatric Association, 1994) and disability was measured using the Sheehan Disability Inventory (SDI) (Sheehan et al., 1996; Bobes et al., 1999). The SDI consists of five items grouped into three scales: (1) disability, consisting of the first three items and assessing the extent to which symptoms interfere with three domains (work, social life, and family life) of the patient's life; (2) perceived stress, which assesses the extent to which stressful events and personal problems have affected the patient's life; and (3) social support, which assesses the support the patient receives as compared to the support needed. The disability scale score is calculated by adding the scores from each of the 3 scale items. A systematic inventory was also used to record demographic variables (age, sex, marital status, educational level, and income-based socioeconomic status), family history of mental disorder, premorbid deafness (defined as hearing loss leading to communication difficulties), premorbid immigration, premorbid head trauma with loss of consciousness, premorbid substance abuse (according to DSM-IV criteria), attempted suicide, marital problems, episodes of physical aggression against others, problems with the law and imprisonment, precipitant factors according to axis IV of DSM-IV, age at onset of DD, age at first psychiatric consultation, form of onset (acute [b3 months] or insidious [N 3 months]), time since onset, course of condition (uninterrupted chronic or phasic with total remission), and use of psychiatric resources (number of psychiatric admissions and visits to the emergency room). 2.3. Statistical analyses We used the chi-square test to compare qualitative variables and the t test for continuous ones. The Fisher exact test was used in the case of 2 × 2 contingency tables with an expected frequency of less than 5. Statistical significance was set at a P value of less than 0.05. SPSS (version 15.5) was used to compute the data.
3. Results 3.1. Gender, demographics, and risk factors Patients (20) who refused to take part did not differ significantly in terms of age or gender to the final sample of 86 DD patients included in the analyses. Demographic characteristics are displayed in Table 1. Women accounted for 61.6% of the sample and men 38.4%. The mean age of women (55.1 years, S.D. = 13.5) was higher than that of men (52.2 years, S.D.= 15.7), although differences were not significant. It was more frequent for men to be unmarried (39.4%) than for women Table 1 Gender differences in sociodemographic characteristics. Delusional disorder (n = 86) Female (n = 53) Age (years) Age at onset (years) Marital status Single Married Separated/divorced Widowed Years in education Lives with No-one Original family Own family Institutions Mean income (€/month) Taking antipsychotic Taking antidepressants (*) P b 0.05 and (**) P b 0.01.
55.1 (S.D. 13.5) 41.4 (S.D. 15.3) 8 29 10 6 6.5
(15.1%) (54.7%) (18.9%) (11.3%) (S.D. 4.9)
Male (n = 33) 52.2 (S.D. 15.8) 36.8 (S.D. 12.4)
Significance (P) 0.362 0.148 0.025*
13 (39.4%) 16 (48.5%) 4 (12.1%) 0 (0.0%) 8.5 (S.D. 5.1) 0.277
10 9 32 2 570.4 47 23
(18.9%) (17.0%) (69.6%) (33.3%) (S.D. 318.1) (88.7%) (43.4%)
7 ( 21.2%) 8 (24.2%) 14 (30.4%) 4 (66.7%) 896.6 (S.D. 476.3) 31 (93.9%) 12 (36.4%)
0.015* 0.705 0.519
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(15.1%), whereas women had a higher prevalence of widowhood (11.3%) than men (0.0%). Socioeconomic status based on mean income in €/month was significantly lower in women than in men. No gender differences were found in medication (antipsychotic or antidepressant) intake. Schizoid and schizotypal premorbid personality disorders were more frequent in men than in women, with significant tendencies. Men had a significantly higher frequency of premorbid substance abuse (30.3%) than women (11.3%). No other differences were found for the remaining DD risk factors (other premorbid personality disorders, premorbid deafness, premorbid immigration, older age at onset, premorbid head trauma with loss of consciousness, and family history of mental disorder). More information on gender differences for other risk factors for and clinical correlates of DD can be found on Supplementary Tables 1 and 2.
gustatory hallucinations. No other differences were found for the remaining clinical variables (supplementary Table 2).
3.2. Gender and clinical and psychopathological correlates of DD
This is the first study to use valid standardized measures to examine a relatively large sample of DD patients with the objective of exploring the different psychosocial and clinical correlates of DD in women and men. We report empirical evidence on the influence of gender on risk factors, clinical correlates, and functionality in DD patients.
Clinical and psychopathological characteristics are listed in Table 2 (see also Supplementary tables). PANSS positive and negative subscales' mean scores were significantly higher in men (15.1, S.D. = 5.4 and 9.9, S.D. = 3.4, respectively) than in women (13.0, S.D. = 3.8 and 9.3, S.D. = 2.1, respectively). Within the PANSS positive subscale, only hallucinations' (P3) mean score was significantly higher in men (1.9, S.D. = 0.9) than women (1.6, S.D. = 0.3). Of the symptoms in the PANSS negative subscale, only the scores for blunted affect (N1) and emotional withdrawal (N2) obtained higher results in men (1.4, S.D. = 0.6 and 1.5, S.D. = 0.8, respectively) than in women (1.0, S.D. = 0.1 and 1.1 S.D. = 0.4, respectively). In addition, the PANSS general psychopathologic subscale mean score was also significantly higher in men (25.6, S.D. = 5.8) than in women (22.6, S.D. = 3.6), mainly as a result of motor retardation (PG7) and unusual thought contents (PG9) mean scores. More men (12.1%) than women (0.0%) had non-prominent
Table 2 Gender differences in DD: psychopathology and other clinical factors. Delusional disorder (n = 86)
Types of DD Persecutory Jealous Somatic Erotomaniac Grandiose Mixed Unspecified Hallucinations (SCID-I) Non-prominent gustatory Total PANSS Positive PANSS Negative PANSS General PANSS Presence of depression (MADRS) Depression severety (MADRS) Cognition (MMSE) Premorbid substance abuse Suicide risk (MINI) Form of onset Insidious Acute GAF SDI: disability Work life Social life Family life
Female (n = 53)
Male (n = 33)
Significance (P)
32 (60.4%) 11 (20.8% ) 1 (1.9 %) 4 (7.5 %) 2 (3.8 %) 3 (5.7 %) 0 (0.0%) 21 (39.6%) 0 (0.0%) 44.9 (S.D. 6.9) 13.0 (S.D. 3.8) 9.3 (S.D. 2.1) 22.6 (S.D. 3.6) 25 (S.D. 47.7) 7.30 (S.D. 6.6) 27.5 (S.D. 2.7) 6 (11.3%) 5 (9.4% )
19 (57.6%) 8 (24.2%) 2 (6.1 %) 0 (0.0%) 2 (6.1%) 2 (6.1 %) 0 (0.0%) 18 (54.5%) 4 (12.1%) 51.6 (S.D. 12.6) 15.1 (S.D. 5.4) 9.9 (S.D. 3.4) 25.6 (S.D. 5.8) 16 (S.D. 50.0) 8.6 (S.D. 8.3) 27.7 (S.D. 2.0) 10 (30.3%) 8 (24.2%)
0.797 0.705 0.556 0.293 0.636 1.000 – 0.176 0.019* 0.002* 0.039* 0.007** 0.005** 0.800 0.440 0.775 0.028* 0.073 0.031*
42 (79.2%) 11 (20.8%) 67.4 (S.D. 9.3) 11.6 (S.D. 7.3) 4.5 (S.D. 3.5) 3.7 (S.D. 2.8) 3.6 (S.D. 2.9)
19 (57.2%) 14 (42.4%) 58.3 (S.D. 12.1) 17.3 (S.D. 7.5) 6.6 (S.D. 3.4) 5.4 (S.D. 3.0) 5.3 (S.D. 3.2)
0.000** 0.001** 0.008** 0.011* 0.012*
(*) P b 0.05 and (**) P b 0.01. Abbreviations: SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders; PANSS, Positive and Negative Syndrome Scale for Schizophrenia; MADRS, Montgomery–Asberg Depression Rating Scale; MMSE, Mini Mental State Examination; MINI, Mini International Neuropsychiatric Interview; SDI, Sheehan Disability Inventory.
3.3. Gender, course and functionality Although mean age at onset of DD in men (36.8, S.D.=12.4) was younger than in women (41.4, S.D. = 15.3), differences were not significant. Men significantly tended to show acute onset more frequently (42.4%) than women (20.8%). Global functioning mean scores (GAF) were significantly lower in men (58.3, S.D.=12.1) than among women (67.4, S.D.=9.3). Disability SDI scores were also significantly higher in men (17.3, S.D.=7.5) than women (11.6, S.D.=7.3). 4. Discussion
4.1. Gender, demographics, and risk factors A remarkable finding in our study was that DD is far more frequent among women (the female-to-male ratio was 1.6:1). This proportion of women is higher than that reported by the largest meta-analysis on the topic based on in-patients diagnosed with criteria from before DSM-III and CIE-8 (when the female-to-male ratio was 1.2:1) (Kendler, 1982), but lower than that reported by recent smaller studies based on DSM-III-R and DSM-IV (female-to-male ratios ranging from 1.9:1 to 3:1) (Marino et al., 1993; Yamada et al., 1998; Bada et al., 2000; Maina et al., 2001). DSM-IV, though, states that the prevalence of DD is roughly the same in both genders (American Psychiatric Association, 1994), but in light of these findings may need revision. Our findings on marital status, suggest that men with DD find it more difficult to start or maintain stable relationships than women and that bachelorhood in men and widowhood in women might favour isolation likely to influence the emergence of DD. Men had a significantly higher frequency of premorbid substance abuse than women, which is consistent with one previous study (Munro and Mok, 1995). Schizoid and schizotypal premorbid personality disorders tended to be more frequent in men than in women, a finding difficult to compare with those of other studies on DD, as ours is the first study on DD to use a standardized structured interview for premorbid personality disorders. Consistent a previous report (Munro, 1998), we found that more women (30.2%) than men (15.2%) tended to present the disorder in old age, although this was not statistically significant, maybe due to insufficient sample size power. 4.2. Gender and clinical and psychopathological correlates of DD Like most of the few previous studies, we did not find gender differences in DD type (Yamada et al., 1998; Hsiao et al., 1999; Bada et al., 2000; de Portugal et al., 2008). Perhaps the most remarkable gender difference in our study was that men presented greater severity of psychotic symptoms both on the global and, particularly, on the negative and general PANSS scales. A moderate excess of positive symptoms among men seems to be mainly accounted for by an increased severity of hallucinations in men, whereas higher scores on the PANSS negative subscale among men seem due to greater severity of blunted affect and emotional withdrawal. These differences do not seem to be related to non-significant gender differences in age, years of illness, or use of antipsychotics and antidepressants. The higher intensity of negative symptoms in men (mean PANSS-N = 9.9) than in women (mean PANSS-N = 9.3) is similar to that observed in most gender studies on paranoid schizophrenia (Shtasel et al., 1992; Szymansky et al., 1995; Cowell et al., 1996), which for some authors is part of a
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continuum of DD in the paranoid spectrum (Kendler et al., 1993; Munro, 1998). However, no previous studies on DD assess the difference in positive and negative psychotic psychopathology between genders using a standard structured interview for psychotic disorders. A plausible neurobiological explanation for different symptom profiles has been suggested in that women, maybe via estrogens, might be protected against more severe forms of psychosis (Leung and Chue, 2000). This is further supported by our finding that men had more nonprominent hallucinations than women. Nevertheless, regarding the core symptom of DD, we did not find differences between the genders in severity of delusion, which is consistent with a previous study (Bada et al., 2000). In agreement with some authors, we found no significant gender differences in the presence or absence of depressive syndrome (Tsiao et al., 1999; Grover et al., 2006) and its severity (Bada et al., 2000). However, our results were not consistent with those of other authors who did find greater comorbidity of depressive disorders among women (Bada et al., 2000; Marino et al., 1993, Maina et al., 2000), or did they support the consideration of Rudden et al. (1983) that the clinical expression of DD in women is more similar to schizoaffective disorder. The latter discrepancy might come from the fact that these other studies did not use a standardized instrument to assess depressive comorbidity. 4.3. Gender and cognition, DD course and functionality No gender differences were found for any of the cognitive measures used. The finding of an earlier mean age at onset in men than in women is congruent with most studies (Rudden et al., 1983; Marino et al., 1993, Tsiao et al., 1999). As to the form of DD onset, we found that men more frequently had an acute onset than women, although earlier studies found no differences (Rudden et al., 1983; Bada et al., 2000). In agreement with the idea of a greater severity of psychosis in men, our study shows a significantly worse functionality among men, which is also congruent with higher scores on negative and other serious psychotic symptoms, such as hallucinations. Thus, GAF mean scores were lower in men while social disability SDI scores were significantly higher in men, both globally and when measured on all three SDI subscales (work, family, and social life). Such poorer global functionality and total disability that we found in men with DD have also been reported elsewhere (Bada et al., 2000) when evaluation of social and labour functionality was made using the Social Self-Evaluation Scale (SASS). 4.4. Limitations, strengths and concluding remarks Our results have several limitations. First, the sample is not homogeneous with respect to gender distribution, but this may reflect a greater prevalence of DD in women. Women were also older, but did not have a longer duration of illness. Second, since our study was a naturalistic one, we did not control for differences in treatment between the two groups; nevertheless, there was no significant difference in the use of antipsychotic and antidepressants between women and men, and patterns of drug prescription were quite homogeneous among the clinicians who participated in the study. Thirdly, our data on course of illness are retrospective and should be interpreted with caution. Finally, the same consideration applies for our finding of poorer functionality among men which may partially be explained by higher medication intake and/or greater symptom severity among men. A strong point of this study is that the sample was fairly large and can be considered representative of DD outpatients in a specific geographical area. However, it should only be generalized to outpatients who have longterm DD and who are in a stable phase of the disease. Finally, we conclude that men with DD of our study, as in most studies in schizophrenia (Usall et al., 2000), had a higher frequency of schizoid and schizotypal premorbid personality disorders and premorbid substance abuse and also more severe symptoms and worse functionality.
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E. de Portugal et al. / Psychiatry Research 177 (2010) 235–239 Munro, A., 1998. Paranoia or delusional disorder. In: Munro, A. (Ed.), Delusional Disorder: Paranoia and Related Illnesses. Cambridge University Press, Cambridge, pp. 45–70. Munro, A., Mok, H., 1995. An overview of treatment on paranoid/delusional disorder. Canadian Journal Psychiatry 10, 610–622. Peralta, V., Cuesta, M.J., 1994. Validación de la escala de los síndromes positivo y negativo (PANSS) en una muestra de esquizofrénicos españoles. Actas LusoEspañolas de Neurología, Psiquiatría y Ciencias Afines 221, 71–177. Rudden, M., Sweeney, J., Frances, A., Gilmore, M., 1983. A comparison of delusional disorders in women and men. American Journal of Psychiatry 140, 1575–1578. Sheehan, D.V., Harnett-Sheehan, K., Raj, B.A., 1996. The Measurement of Disability. International Clinical Psychopharmacology 11, 89–95. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Janavs, J., Weiller, E., Keskiner, A., Schinaka, J., Knapp, E., Sheehan, M.F., Dunbar, G.C., 1997. The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. European Psychiatry 12, 232–241.
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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p s y c h r e s
Gender differences in delusional disorder: Evidence from an outpatient sample Enrique de Portugal a, Nieves González b, Vilaplana, Miriam b, Josep M. Haro b,c, Judit Usall b,c, Jorge A. Cervilla d,e,⁎ a
Department of Psychiatry, Hospital Gregorio Marañon, Madrid, Spain Research and Development Unit, Sant Joan de Déu-SSM, Barcelona, Spain CIBER en Salud Mental (CIBERSAM) nodo de Sant Joan de Déu, Barcelona, Spain d Department of Psychiatry and Institute of Neurosciences, University of Granada, Spain e CIBER en Salud Mental (CIBERSAM) nodo de la Universidad de Granada, Spain b c
a r t i c l e
i n f o
Article history: Received 27 May 2009 Received in revised form 21 November 2009 Accepted 22 February 2010 Keywords: Delusial disorder Gender Paranoia Psychosis
a b s t r a c t Our objective was to study gender differences in delusional disorder (DD), by comparing potential risk factors, clinical correlates, illness course characteristics, and functionality. The sample was composed of 86 outpatients with DD (according to the SCID-I for DSM-IV criteria). The following assessment instruments were used service use and demographic questionnaires, Standardized Assessment of Personality (SAP), the Positive and Negative Symptom Scale (PANSS), Montgomery–Asberg Depression Rating Scale (MADRS), Mini-Mental State Examination (MMSE), Mini International Neuropsychiatry Interview (MINI), Sheehan Disability Inventory (SDI), and the Global Assessment of Functioning (GAF) scale. The female-to-male ratio was 1.6:1. Men were more likely to be single, while women were more likely to be widows. Men had a greater frequency of schizoid and schizotypal premorbid personality disorders and of premorbid substance abuse. There were no differences for other risk factors (immigration, deafness, late onset, other personality disorders, and family history). Men were younger at onset and more frequently had acute onset of the disorder. Men had more severe symptoms (higher score on the global or separate PANSS scales). There were no gender differences for the remaining symptomatological variables (types of DD, presence and severity of depression, presence of hallucinations, severity of global cognitive functioning and presence of axis I comorbidity). Global and partial (work, family, and social) functioning was significantly poorer among men. Course type and consumption of resources appeared to be similar. We conclude that men with DD had significantly more severe symptoms and worse functionality. They also had a higher frequency of schizoid and schizotypal premorbid personality disorders and premorbid substance abuse. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Unlike gender differences in schizophrenia and affective disorders, the existence of gender differences in delusional disorder (DD, previously known as clinical paranoia) has been poorly studied. As DD has been described primarily according to a male prototype, the diagnosis of DD in women may differ from that of the male prototype (Rudden et al., 1983). The few existing empirical studies in DD are based on small samples, use different diagnostic criteria, are usually poorly designed, and rarely compare clinical differences between both sexes. To the best of our knowledge, there are only two specific studies on gender differences in DD. Rudden's methodologically limited study retrospectively evaluated the clinical differences between 44 females and 44 males diagnosed with DSM-III criteria (Rudden et al., 1983), whereas Bada's well-designed observational study used DSM-IV criteria, ⁎ Corresponding author. CIBERSAM, Section of Psychiatry and Institute of Neurosciences, University of Granada, Spain. Tel.: +34 958 242017. E-mail address: [email protected] (J.A. Cervilla). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.02.017
although the sample size is small (N = 35) (Bada et al., 2000). Prevalence rates are higher in women. Thus, Kendler's (1982) metaanalysis found that female patients slightly outnumbered male patients (the female-to-male ratio was 1.2:1) (Kendler, 1982). Later, smaller studies on DD found an even higher female-to-male ratio (ranging from 1.9:1 to 3:1) (Marino et al., 1993; Yamada et al., 1998; Bada et al., 2000; Maina et al., 2001). Onset occurs at an earlier age in men (Munro, 1991; Marino et al., 1993; Yamada et al., 1998; Hsiao et al., 1999). Men are also more frequently single, whereas female subjects were more frequently widowed (Marino et al., 1993; Munro and Mok, 1995), although other studies did not find any differences in terms of marital status, socioeconomic or educational status (Rudden et al., 1983; Bada et al., 2000). There are even scarcer evidence for gender differences regarding potential risk factors for DD, including late age at onset, low socioeconomic status, social isolation, immigration, sensory deficits, personality, and family transmission (Manschreck, 1996). Nonetheless, presence of interpersonal precipitating factors and late age at onset was found more frequent in females (Rudden et al., 1983; Munro, 1998). In
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addition, the role of subtle organic factors, such as premorbid head trauma with loss of consciousness and premorbid substance abuse may also be important in triggering the onset of DD, particularly among men (Munro and Mok, 1995). Few and controversial gender differences in the clinical characteristics of DD have also been described. According to DSM-III criteria, Rudden et al. (1983) found a greater preponderance of erotomaniac delusions among women, whereas most recent studies using criteria from DSM-III-R (does not include mixed type) and DSM-IV found no gender differences between the different types of DD (Yamada et al., 1998; Hsiao et al., 1999; Bada et al., 2000; de Portugal et al., 2008). Bada et al. (2000) did not find significant gender differences in the severity of delusions using the Brown Assessment of Beliefs Scale (BABS). There are no studies assessing gender differences in positive and negative psychotic psychopathology using standardized instruments. Rudden et al. (1983) found a greater severity of affective symptoms in women and considered that symptomatic expression of DD is more similar to schizoaffective disorder among women. A recent study also found no differences in frequency of depressive disorders (Grover et al., 2007). Further, Bada et al. (2000) found no significant differences in depression severity, although they did found greater comorbidity of depressive disorders among women, as did other authors (Marino et al., 1993; Maina et al., 2001). It is striking that no studies so far have used standardized instruments to assess global cognitive functioning in DD between the genders. Finally, there are few reports of gender differences in the course of DD. While some studies found that men consult a psychiatrist earlier after the onset (Kendler, 1982; Jorgensen and Jorgensen, 1985; Yamada et al., 1998), others found no significant differences (Hsiao et al., 1999; Bada et al., 2000). Bada et al. (2000) found no gender differences in the form of onset (acute or insidious), type of course (phasic or chronic), or degree of social and labour functionality. This paucity of empirical and systematic descriptive studies provides us with a unique opportunity to explore and describe gender differences in DD using a relatively large, thoroughly studied sample. Our three main objectives were: (1) to explore gender differences in the risk factors for DD in the absence of previous studies; (2) to examine symptomatological differences between men and women, since previous results are contradictory; and (3) to determine social functioning by means of scales, with the hypothesis that women function better. 2. Methods 2.1. Sample A cross-sectional sample of 106 individuals with a diagnosis of DD was selected randomly from a computerized case register of five Community Mental Health Centers (CMHC) belonging to Sant Joan de Déu-Mental Health Services (SJD-MHS) in Barcelona (Spain), as described elsewhere (de Portugal et al., 2008). Inclusion criteria were: (a) primary diagnosis of DD (DSM-IV) (American Psychiatric Association, 1994), (b) more than 18 years of age, (c) to live in the catchment areas of the participating CMHC, (d) to at least have received one outpatient visit during the 6 months previous to the beginning of the study, (e) reference psychiatrist's approval to participate in the study, and (f) patient's agreement to participate. Exclusion criteria were: (a) diagnosis of mental retardation; and (b) unfulfillment of the diagnostic confirmation of TD using the Structured Clinical Interview for DSM-IV Axis I Disorders (psychosis module) (Gómez Beneyto, 1995; First et al., 1997). Six patients refused to participate in the study, and in eight patients the reference psychiatrist did not approve their participation in the study and in six patients the diagnosis of DD was not confirmed according to the SCID-I (three fulfilled criteria for the schizophrenia, one for the schizoaffective disorder, one for the psychotic disorder due to medical disease and another one for the psychotic disorder due to substance abuse). Eighty-six patients finished the evaluation, constituting in this way the final sample of our study. All the patients were provided with a complete description of the study and gave their written informed consent to participate after they had been invited to do so by a letter from their psychiatrist. The study was approved by the local research ethics committee. 2.2. Variables and measurements All patients were evaluated by a postgraduate psychology student trained to use all the study instruments. The diagnosis of DD was validated using the psychosis module of the Structured Clinical Interview for DSM-IV axis I disorder, clinical version (SCID-I CV) (Gómez Beneyto, 1995; First et al., 1997). Patients were assigned to one of seven
DSM-IV DD types (persecutory, jealous, somatic, erotomaniac, grandiose, mixed, and unspecified). The Standardized Assessment of Personality (SAP) (Mann et al., 1981) was used to assess premorbid personality. Psychotic psychopathology was assessed using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) (Kay et al., 1987; Peralta and Cuesta, 1994) and history of psychotic psychopathology was examined using Module B (psychotic and associated symptoms) of the SCID-I CV (Gómez Beneyto, 1995; First et al., 1997). The presence and severity of depressive symptoms were assessed using the Montgomery–Asberg Depression Rating Scale (MADRS) (Montgomery and Asberg, 1979; Martínez et al., 1991). Global cognitive functioning was evaluated with the Mini-Mental State Examination (MMSE) (Folstein et al., 1975; Lobo et al., 1999). Coexisting DSM-IV axis I psychiatric disorders were diagnosed using the Mini International Neuropsychiatric Interview (MINI) for DSM-IV (Sheehan et al., 1997; Bobes et al., 1997; Sheehan et al., 1998). Global functioning was assessed using the Global Assessment of Functioning (GAF) scale (American Psychiatric Association, 1994) and disability was measured using the Sheehan Disability Inventory (SDI) (Sheehan et al., 1996; Bobes et al., 1999). The SDI consists of five items grouped into three scales: (1) disability, consisting of the first three items and assessing the extent to which symptoms interfere with three domains (work, social life, and family life) of the patient's life; (2) perceived stress, which assesses the extent to which stressful events and personal problems have affected the patient's life; and (3) social support, which assesses the support the patient receives as compared to the support needed. The disability scale score is calculated by adding the scores from each of the 3 scale items. A systematic inventory was also used to record demographic variables (age, sex, marital status, educational level, and income-based socioeconomic status), family history of mental disorder, premorbid deafness (defined as hearing loss leading to communication difficulties), premorbid immigration, premorbid head trauma with loss of consciousness, premorbid substance abuse (according to DSM-IV criteria), attempted suicide, marital problems, episodes of physical aggression against others, problems with the law and imprisonment, precipitant factors according to axis IV of DSM-IV, age at onset of DD, age at first psychiatric consultation, form of onset (acute [b3 months] or insidious [N 3 months]), time since onset, course of condition (uninterrupted chronic or phasic with total remission), and use of psychiatric resources (number of psychiatric admissions and visits to the emergency room). 2.3. Statistical analyses We used the chi-square test to compare qualitative variables and the t test for continuous ones. The Fisher exact test was used in the case of 2 × 2 contingency tables with an expected frequency of less than 5. Statistical significance was set at a P value of less than 0.05. SPSS (version 15.5) was used to compute the data.
3. Results 3.1. Gender, demographics, and risk factors Patients (20) who refused to take part did not differ significantly in terms of age or gender to the final sample of 86 DD patients included in the analyses. Demographic characteristics are displayed in Table 1. Women accounted for 61.6% of the sample and men 38.4%. The mean age of women (55.1 years, S.D. = 13.5) was higher than that of men (52.2 years, S.D.= 15.7), although differences were not significant. It was more frequent for men to be unmarried (39.4%) than for women Table 1 Gender differences in sociodemographic characteristics. Delusional disorder (n = 86) Female (n = 53) Age (years) Age at onset (years) Marital status Single Married Separated/divorced Widowed Years in education Lives with No-one Original family Own family Institutions Mean income (€/month) Taking antipsychotic Taking antidepressants (*) P b 0.05 and (**) P b 0.01.
55.1 (S.D. 13.5) 41.4 (S.D. 15.3) 8 29 10 6 6.5
(15.1%) (54.7%) (18.9%) (11.3%) (S.D. 4.9)
Male (n = 33) 52.2 (S.D. 15.8) 36.8 (S.D. 12.4)
Significance (P) 0.362 0.148 0.025*
13 (39.4%) 16 (48.5%) 4 (12.1%) 0 (0.0%) 8.5 (S.D. 5.1) 0.277
10 9 32 2 570.4 47 23
(18.9%) (17.0%) (69.6%) (33.3%) (S.D. 318.1) (88.7%) (43.4%)
7 ( 21.2%) 8 (24.2%) 14 (30.4%) 4 (66.7%) 896.6 (S.D. 476.3) 31 (93.9%) 12 (36.4%)
0.015* 0.705 0.519
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(15.1%), whereas women had a higher prevalence of widowhood (11.3%) than men (0.0%). Socioeconomic status based on mean income in €/month was significantly lower in women than in men. No gender differences were found in medication (antipsychotic or antidepressant) intake. Schizoid and schizotypal premorbid personality disorders were more frequent in men than in women, with significant tendencies. Men had a significantly higher frequency of premorbid substance abuse (30.3%) than women (11.3%). No other differences were found for the remaining DD risk factors (other premorbid personality disorders, premorbid deafness, premorbid immigration, older age at onset, premorbid head trauma with loss of consciousness, and family history of mental disorder). More information on gender differences for other risk factors for and clinical correlates of DD can be found on Supplementary Tables 1 and 2.
gustatory hallucinations. No other differences were found for the remaining clinical variables (supplementary Table 2).
3.2. Gender and clinical and psychopathological correlates of DD
This is the first study to use valid standardized measures to examine a relatively large sample of DD patients with the objective of exploring the different psychosocial and clinical correlates of DD in women and men. We report empirical evidence on the influence of gender on risk factors, clinical correlates, and functionality in DD patients.
Clinical and psychopathological characteristics are listed in Table 2 (see also Supplementary tables). PANSS positive and negative subscales' mean scores were significantly higher in men (15.1, S.D. = 5.4 and 9.9, S.D. = 3.4, respectively) than in women (13.0, S.D. = 3.8 and 9.3, S.D. = 2.1, respectively). Within the PANSS positive subscale, only hallucinations' (P3) mean score was significantly higher in men (1.9, S.D. = 0.9) than women (1.6, S.D. = 0.3). Of the symptoms in the PANSS negative subscale, only the scores for blunted affect (N1) and emotional withdrawal (N2) obtained higher results in men (1.4, S.D. = 0.6 and 1.5, S.D. = 0.8, respectively) than in women (1.0, S.D. = 0.1 and 1.1 S.D. = 0.4, respectively). In addition, the PANSS general psychopathologic subscale mean score was also significantly higher in men (25.6, S.D. = 5.8) than in women (22.6, S.D. = 3.6), mainly as a result of motor retardation (PG7) and unusual thought contents (PG9) mean scores. More men (12.1%) than women (0.0%) had non-prominent
Table 2 Gender differences in DD: psychopathology and other clinical factors. Delusional disorder (n = 86)
Types of DD Persecutory Jealous Somatic Erotomaniac Grandiose Mixed Unspecified Hallucinations (SCID-I) Non-prominent gustatory Total PANSS Positive PANSS Negative PANSS General PANSS Presence of depression (MADRS) Depression severety (MADRS) Cognition (MMSE) Premorbid substance abuse Suicide risk (MINI) Form of onset Insidious Acute GAF SDI: disability Work life Social life Family life
Female (n = 53)
Male (n = 33)
Significance (P)
32 (60.4%) 11 (20.8% ) 1 (1.9 %) 4 (7.5 %) 2 (3.8 %) 3 (5.7 %) 0 (0.0%) 21 (39.6%) 0 (0.0%) 44.9 (S.D. 6.9) 13.0 (S.D. 3.8) 9.3 (S.D. 2.1) 22.6 (S.D. 3.6) 25 (S.D. 47.7) 7.30 (S.D. 6.6) 27.5 (S.D. 2.7) 6 (11.3%) 5 (9.4% )
19 (57.6%) 8 (24.2%) 2 (6.1 %) 0 (0.0%) 2 (6.1%) 2 (6.1 %) 0 (0.0%) 18 (54.5%) 4 (12.1%) 51.6 (S.D. 12.6) 15.1 (S.D. 5.4) 9.9 (S.D. 3.4) 25.6 (S.D. 5.8) 16 (S.D. 50.0) 8.6 (S.D. 8.3) 27.7 (S.D. 2.0) 10 (30.3%) 8 (24.2%)
0.797 0.705 0.556 0.293 0.636 1.000 – 0.176 0.019* 0.002* 0.039* 0.007** 0.005** 0.800 0.440 0.775 0.028* 0.073 0.031*
42 (79.2%) 11 (20.8%) 67.4 (S.D. 9.3) 11.6 (S.D. 7.3) 4.5 (S.D. 3.5) 3.7 (S.D. 2.8) 3.6 (S.D. 2.9)
19 (57.2%) 14 (42.4%) 58.3 (S.D. 12.1) 17.3 (S.D. 7.5) 6.6 (S.D. 3.4) 5.4 (S.D. 3.0) 5.3 (S.D. 3.2)
0.000** 0.001** 0.008** 0.011* 0.012*
(*) P b 0.05 and (**) P b 0.01. Abbreviations: SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders; PANSS, Positive and Negative Syndrome Scale for Schizophrenia; MADRS, Montgomery–Asberg Depression Rating Scale; MMSE, Mini Mental State Examination; MINI, Mini International Neuropsychiatric Interview; SDI, Sheehan Disability Inventory.
3.3. Gender, course and functionality Although mean age at onset of DD in men (36.8, S.D.=12.4) was younger than in women (41.4, S.D. = 15.3), differences were not significant. Men significantly tended to show acute onset more frequently (42.4%) than women (20.8%). Global functioning mean scores (GAF) were significantly lower in men (58.3, S.D.=12.1) than among women (67.4, S.D.=9.3). Disability SDI scores were also significantly higher in men (17.3, S.D.=7.5) than women (11.6, S.D.=7.3). 4. Discussion
4.1. Gender, demographics, and risk factors A remarkable finding in our study was that DD is far more frequent among women (the female-to-male ratio was 1.6:1). This proportion of women is higher than that reported by the largest meta-analysis on the topic based on in-patients diagnosed with criteria from before DSM-III and CIE-8 (when the female-to-male ratio was 1.2:1) (Kendler, 1982), but lower than that reported by recent smaller studies based on DSM-III-R and DSM-IV (female-to-male ratios ranging from 1.9:1 to 3:1) (Marino et al., 1993; Yamada et al., 1998; Bada et al., 2000; Maina et al., 2001). DSM-IV, though, states that the prevalence of DD is roughly the same in both genders (American Psychiatric Association, 1994), but in light of these findings may need revision. Our findings on marital status, suggest that men with DD find it more difficult to start or maintain stable relationships than women and that bachelorhood in men and widowhood in women might favour isolation likely to influence the emergence of DD. Men had a significantly higher frequency of premorbid substance abuse than women, which is consistent with one previous study (Munro and Mok, 1995). Schizoid and schizotypal premorbid personality disorders tended to be more frequent in men than in women, a finding difficult to compare with those of other studies on DD, as ours is the first study on DD to use a standardized structured interview for premorbid personality disorders. Consistent a previous report (Munro, 1998), we found that more women (30.2%) than men (15.2%) tended to present the disorder in old age, although this was not statistically significant, maybe due to insufficient sample size power. 4.2. Gender and clinical and psychopathological correlates of DD Like most of the few previous studies, we did not find gender differences in DD type (Yamada et al., 1998; Hsiao et al., 1999; Bada et al., 2000; de Portugal et al., 2008). Perhaps the most remarkable gender difference in our study was that men presented greater severity of psychotic symptoms both on the global and, particularly, on the negative and general PANSS scales. A moderate excess of positive symptoms among men seems to be mainly accounted for by an increased severity of hallucinations in men, whereas higher scores on the PANSS negative subscale among men seem due to greater severity of blunted affect and emotional withdrawal. These differences do not seem to be related to non-significant gender differences in age, years of illness, or use of antipsychotics and antidepressants. The higher intensity of negative symptoms in men (mean PANSS-N = 9.9) than in women (mean PANSS-N = 9.3) is similar to that observed in most gender studies on paranoid schizophrenia (Shtasel et al., 1992; Szymansky et al., 1995; Cowell et al., 1996), which for some authors is part of a
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continuum of DD in the paranoid spectrum (Kendler et al., 1993; Munro, 1998). However, no previous studies on DD assess the difference in positive and negative psychotic psychopathology between genders using a standard structured interview for psychotic disorders. A plausible neurobiological explanation for different symptom profiles has been suggested in that women, maybe via estrogens, might be protected against more severe forms of psychosis (Leung and Chue, 2000). This is further supported by our finding that men had more nonprominent hallucinations than women. Nevertheless, regarding the core symptom of DD, we did not find differences between the genders in severity of delusion, which is consistent with a previous study (Bada et al., 2000). In agreement with some authors, we found no significant gender differences in the presence or absence of depressive syndrome (Tsiao et al., 1999; Grover et al., 2006) and its severity (Bada et al., 2000). However, our results were not consistent with those of other authors who did find greater comorbidity of depressive disorders among women (Bada et al., 2000; Marino et al., 1993, Maina et al., 2000), or did they support the consideration of Rudden et al. (1983) that the clinical expression of DD in women is more similar to schizoaffective disorder. The latter discrepancy might come from the fact that these other studies did not use a standardized instrument to assess depressive comorbidity. 4.3. Gender and cognition, DD course and functionality No gender differences were found for any of the cognitive measures used. The finding of an earlier mean age at onset in men than in women is congruent with most studies (Rudden et al., 1983; Marino et al., 1993, Tsiao et al., 1999). As to the form of DD onset, we found that men more frequently had an acute onset than women, although earlier studies found no differences (Rudden et al., 1983; Bada et al., 2000). In agreement with the idea of a greater severity of psychosis in men, our study shows a significantly worse functionality among men, which is also congruent with higher scores on negative and other serious psychotic symptoms, such as hallucinations. Thus, GAF mean scores were lower in men while social disability SDI scores were significantly higher in men, both globally and when measured on all three SDI subscales (work, family, and social life). Such poorer global functionality and total disability that we found in men with DD have also been reported elsewhere (Bada et al., 2000) when evaluation of social and labour functionality was made using the Social Self-Evaluation Scale (SASS). 4.4. Limitations, strengths and concluding remarks Our results have several limitations. First, the sample is not homogeneous with respect to gender distribution, but this may reflect a greater prevalence of DD in women. Women were also older, but did not have a longer duration of illness. Second, since our study was a naturalistic one, we did not control for differences in treatment between the two groups; nevertheless, there was no significant difference in the use of antipsychotic and antidepressants between women and men, and patterns of drug prescription were quite homogeneous among the clinicians who participated in the study. Thirdly, our data on course of illness are retrospective and should be interpreted with caution. Finally, the same consideration applies for our finding of poorer functionality among men which may partially be explained by higher medication intake and/or greater symptom severity among men. A strong point of this study is that the sample was fairly large and can be considered representative of DD outpatients in a specific geographical area. However, it should only be generalized to outpatients who have longterm DD and who are in a stable phase of the disease. Finally, we conclude that men with DD of our study, as in most studies in schizophrenia (Usall et al., 2000), had a higher frequency of schizoid and schizotypal premorbid personality disorders and premorbid substance abuse and also more severe symptoms and worse functionality.
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