Gender and First Psychotic Episodes in Adolescence

  • Álvaro Andreu
  • Maria Juncal Ruiz
  • Ernesto José Verdura Vizcaino
  • Beatriz Payá-GonzálezEmail author


Research findings in first psychotic episodes in adolescence reveal the existence of differences between men and women in the clinical characteristics of the illness. Biological differences between men and women interacting with the predisposing factors that may, in turn, be influenced by social and cultural factors may explain differences in the etiopathogenesis and clinical expression of psychosis between males and females.

The male gender could lead to increased susceptibility to neurodevelopmental abnormalities as well as to a predisposition to substance abuse that could confer to the male gender to be more vulnerable to suffer more severe psychosis of neurodevelopmental origin.

On the other hand, the stress and traumatic experiences as a risk factor for psychosis may have a greater weight in the female gender. Given this, we should consider the possible predominance of the female gender in psychotic disorders associated with trauma.


Adolescent First psychotic episode Gender 


  1. 1.
    Díaz-Caneja CM, Pina-Camacho L, Rodríguez-Quiroga A, Fraguas D, Parellada M, Arango C. Predictors of outcome in early-onset psychosis: a systematic review. Npj Schizophr. 2015;1:14005.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Häfner H, Maurer K, Löffler W, Fätkenheuer B, Heiden WAD, Riecher-Rössler A, et al. The epidemiology of early schizophrenia: influence of age and gender on onset and early course. Br J Psychiatry. 1994;164(S23):29–38.CrossRefGoogle Scholar
  3. 3.
    Schimmelmann BG, Conus P, Cotton S, McGorry PD, Lambert M. Pre-treatment, baseline, and outcome differences between early-onset and adult-onset psychosis in an epidemiological cohort of 636 first-episode patients. Schizophr Res. 2007;95(1–3):1–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Stevens JR, Prince JB, Prager LM, Stern TA. Psychotic disorders in children and adolescents: a primer on contemporary evaluation and management. Prim Care Companion CNS Disord. 2014;16(2):13f01514.Google Scholar
  5. 5.
    Cotton SM, Lambert M, Schimmelmann BG, Foley DL, Morley KI, McGorry PD, et al. Gender differences in premorbid, entry, treatment, and outcome characteristics in a treated epidemiological sample of 661 patients with first episode psychosis. Schizophr Res. 2009;114(1–3):17–24.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Chang WC, Tang JY, Hui CL, Lam MM, Chan SK, Wong GH, et al. Prediction of remission and recovery in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study. Aust N Z J Psychiatry. 2012;46(2):100–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Cocchi A, Lora A, Meneghelli A, La Greca E, Pisano A, Cascio MT, et al. Sex differences in first-episode psychosis and in people at ultra-high risk. Psychiatry Res. 2014;215(2):314–22.PubMedCrossRefGoogle Scholar
  8. 8.
    Häfner H, Maurer K, an der Heiden W. ABC Schizophrenia study: an overview of results since 1996. Soc Psychiatry Psychiatr Epidemiol. 2013;48(7):1021–31.PubMedCrossRefGoogle Scholar
  9. 9.
    Riecher-Rössler A, Butler S, Kulkarni J. Sex and gender differences in schizophrenic psychoses—a critical review. Arch Womens Ment Health [Internet]. 16 May 2018 [cited 2018 Aug 27]. Available at:
  10. 10.
    Riecher-Rössler A, Löffler W, Munk-Jørgensen P. What do we really know about late-onset schizophrenia? Eur Arch Psychiatry Clin Neurosci. 1997;247(4):195–208.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Lewine RR, et al. Effect of diagnostic criteria on the ratio of male to female schizophrenic patients. Am J Psychiatry. 1984;141(1):84–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Filatova S, Marttila R, Koivumaa-Honkanen H, Nordström T, Veijola J, Mäki P, et al. A comparison of the cumulative incidence and early risk factors for psychotic disorder in young adults in the Northern Finland Birth Cohorts 1966 and 1986. Epidemiol Psychiatr Sci. 2017;26(03):314–24.PubMedCrossRefGoogle Scholar
  13. 13.
    Aleman A, Kahn RS, Selten J. Sex differences in the risk of schizophrenia: evidence from meta-analysis. Arch Gen Psychiatry. 2003;60(6):565–71.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Barajas A, Ochoa S, Obiols JE, Lalucat-Jo L. Gender differences in individuals at high-risk of psychosis: a comprehensive literature review. ScientificWorldJournal. 2015;2015:430735.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Hayashi N, Igarashi Y, Yamashina M, Suda K. Is there a gender difference in a factorial structure of the positive and negative syndrome scale? A test by structural equation modeling. Psychopathology. 2002;35(1):28–35.PubMedCrossRefGoogle Scholar
  16. 16.
    Ochoa S, Usall J, Cobo J, Labad X, Kulkarni J. Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review. Schizophr Res Treat [Internet]. 2012 [cited 2018 Jul 20]. Available at:
  17. 17.
    Kotlicka-Antczak M, Pawełczyk T, Podgórski M, Żurner N, Karbownik MS, Pawełczyk A. Polish individuals with an at-risk mental state: demographic and clinical characteristics. Early Interv Psychiatry. 2016;12(3):391–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Heitz U, Studerus E, Menghini-Müller S, Papmeyer M, Egloff L, Ittig S, et al. Gender differences in first self-perceived signs and symptoms in patients with an at-risk mental state and first-episode psychosis. Early Interv Psychiatry [Internet]. 13 Dec 2017 [cited 2018 Sept 11]. Available at: PubMedCrossRefGoogle Scholar
  19. 19.
    Thorup A, Petersen L, Jeppesen P, Ohlenschlaeger J, Christensen T, Krarup G, et al. Gender differences in young adults with first-episode schizophrenia spectrum disorders at baseline in the Danish OPUS study. J Nerv Ment Dis. 2007;195(5):396–405.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Moukas G, Gourzis P, Beratis IN, Beratis S. Sex differences in prepsychotic “prodromal” symptomatology and its association with Positive and Negative Syndrome Scale active phase psychopathology in male and female patients. Compr Psychiatry. 2010;51(5):546–51.PubMedCrossRefGoogle Scholar
  21. 21.
    Bertani M, Lasalvia A, Bonetto C, Tosato S, Cristofalo D, Bissoli S, et al. The influence of gender on clinical and social characteristics of patients at psychosis onset: a report from the Psychosis Incident Cohort Outcome Study (PICOS). Psychol Med. 2012;42(4):769–80.PubMedCrossRefGoogle Scholar
  22. 22.
    González-Rodríguez A, Studerus E, Spitz A, Bugra H, Aston J, Borgwardt S, et al. Gender differences in the psychopathology of emerging psychosis. Isr J Psychiatry Relat Sci. 2014;51(2):85–92.PubMedGoogle Scholar
  23. 23.
    Szymanski S, Lieberman JA, Alvir JM, Mayerhoff D, Loebel A, Geisler S, et al. Gender differences in onset of illness, treatment response, course, and biologic indexes in first-episode schizophrenic patients. Am J Psychiatry. 1995;152(5):698–703.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Leung A, Chue P. Sex differences in schizophrenia, a review of the literature. Acta Psychiatr Scand Suppl. 2000;401:3–38.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Larsen TK, McGlashan TH, Johannessen JO, Vibe-Hansen L. First-episode schizophrenia: II. Premorbid patterns by gender. Schizophr Bull. 1996;22(2):257–69.PubMedCrossRefGoogle Scholar
  26. 26.
    Chang WC, Tang JYM, Hui CLM, Wong GHY, Chan SKW, Lee EHM, et al. The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: a prospective three-year follow-up study. Psychiatry Res. 2013;209(3):353–60.PubMedCrossRefGoogle Scholar
  27. 27.
    Hassan GAM, Taha GRA. Long term functioning in early onset psychosis: two years prospective follow-up study. Behav Brain Funct BBF. 2011;7:28.PubMedCrossRefGoogle Scholar
  28. 28.
    Riecher-Rössler A. Oestrogens, prolactin, hypothalamic-pituitary-gonadal axis, and schizophrenic psychoses. Lancet Psychiatry. 2017;4(1):63–72.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Kulkarni J, Gavrilidis E, Worsley R, Van Rheenen T, Hayes E. The role of estrogen in the treatment of men with schizophrenia. Int J Endocrinol Metab. 2013;11(3):129–36.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Riecher-Rössler A, McGorry PD. Early detection and intervention in psychosis. In: Riecher-Rössler A, McGorry PD, editors. Key issues in mental health [Internet]. Basel: S. Karger AG; 2016. p. 179–89.. [cited 2018 Sept 11]. Available at: Scholar
  31. 31.
    Shah J, Mizrahi R, McKenzie K. The four dimensions: a model for the social aetiology of psychosis. Br J Psychiatry J Ment Sci. 2011;199(1):11–4.CrossRefGoogle Scholar
  32. 32.
    United Nations, Office on Drugs and Crime. World drug report 2016. 2016.Google Scholar
  33. 33.
    Green AI, Tohen MF, Hamer RM, Strakowski SM, Lieberman JA, Glick I, et al. First episode schizophrenia-related psychosis and substance use disorders: acute response to olanzapine and haloperidol. Schizophr Res. 2004;66(2–3):125–35.PubMedCrossRefGoogle Scholar
  34. 34.
    Lange EH, Nesvåg R, Ringen PA, Hartberg CB, Haukvik UK, Andreassen OA, et al. One year follow-up of alcohol and illicit substance use in first-episode psychosis: does gender matter? Compr Psychiatry. 2014;55(2):274–82.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Kuzenko N, Sareen J, Beesdo-Baum K, Perkonigg A, Höfler M, Simm J, et al. Associations between use of cocaine, amphetamines, or psychedelics and psychotic symptoms in a community sample. Acta Psychiatr Scand. 2011;123(6):466–74.PubMedCrossRefGoogle Scholar
  36. 36.
    McClellan J, Stock S. Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry. 2013;52(9):976–90.PubMedCrossRefGoogle Scholar
  37. 37.
    Khan SS, Secades-Villa R, Okuda M, Wang S, Pérez-Fuentes G, Kerridge BT, et al. Gender differences in cannabis use disorders: results from the National Epidemiologic Survey of Alcohol and Related Conditions. Drug Alcohol Depend. 2013;130(1):101–8.PubMedCrossRefGoogle Scholar
  38. 38.
    MacArthur GJ, Smith MC, Melotti R, Heron J, Macleod J, Hickman M, et al. Patterns of alcohol use and multiple risk behaviour by gender during early and late adolescence: the ALSPAC cohort. J Public Health. 2012;34(Suppl 1):i20–30.CrossRefGoogle Scholar
  39. 39.
    Carney R, Cotter J, Firth J, Bradshaw T, Yung AR. Cannabis use and symptom severity in individuals at ultra high risk for psychosis: a meta-analysis. Acta Psychiatr Scand. 2017;136(1):5–15.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Crocker CE, Tibbo PG. The interaction of gender and cannabis in early phase psychosis. Schizophr Res. 2018;194:18–25.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Myles H, Myles N, Large M. Cannabis use in first episode psychosis: Meta-analysis of prevalence, and the time course of initiation and continued use. Aust N Z J Psychiatry. 2016;50(3):208–19.PubMedCrossRefGoogle Scholar
  42. 42.
    Stefanis NC, Dragovic M, Power BD, Jablensky A, Castle D, Morgan VA. Age at initiation of cannabis use predicts age at onset of psychosis: the 7- to 8-year trend. Schizophr Bull. 2013;39(2):251–4.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    McQueeny T, Padula CB, Price J, Medina KL, Logan P, Tapert SF. Gender effects on amygdala morphometry in adolescent marijuana users. Behav Brain Res. 2011;224(1):128–34.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    James A, James C, Thwaites T. The brain effects of cannabis in healthy adolescents and in adolescents with schizophrenia: a systematic review. Psychiatry Res Neuroimaging. 2013;214(3):181–9.CrossRefGoogle Scholar
  45. 45.
    Donoghue K, Doody GA, Murray RM, Jones PB, Morgan C, Dazzan P, et al. Cannabis use, gender and age of onset of schizophrenia: data from the ÆSOP study. Psychiatry Res. 2014;215(3):528–32.PubMedCrossRefGoogle Scholar
  46. 46.
    Varese F, Smeets F, Drukker M, Lieverse R, Lataster T, Viechtbauer W, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull. 2012;38(4):661–71.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Morgan C, Fisher H. Environment and schizophrenia: environmental factors in schizophrenia: childhood trauma—a critical review. Schizophr Bull. 2007;33(1):3–10.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005;112(5):330–50.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Pruessner M, King S, Vracotas N, Abadi S, Iyer S, Malla AK, et al. Gender differences in childhood trauma in first episode psychosis: association with symptom severity over two years. Schizophr Res [Internet]. June 2018 [cited 2018 Aug 22]. Available at:
  50. 50.
    Fisher H, Morgan C, Dazzan P, Craig TK, Morgan K, Hutchinson G, et al. Gender differences in the association between childhood abuse and psychosis. Br J Psychiatry. 2009;194(4):319–25.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Stumbo SP, Yarborough BJH, Paulson RI, Green CA. The impact of adverse child and adult experiences on recovery from serious mental illness. Psychiatr Rehabil J. 2015;38(4):320–7.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.
    Duhig M, Patterson S, Connell M, Foley S, Capra C, Dark F, et al. The prevalence and correlates of childhood trauma in patients with early psychosis. Aust N Z J Psychiatry. 2015;49(7):651–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Schalinski I, Fischer Y, Rockstroh B. Impact of childhood adversities on the short-term course of illness in psychotic spectrum disorders. Psychiatry Res. 2015;228(3):633–40.PubMedCrossRefGoogle Scholar
  54. 54.
    Trotta A, Murray RM, David AS, Kolliakou A, O’Connor J, Di Forti M, et al. Impact of different childhood adversities on 1-year outcomes of psychotic disorder in the genetics and psychosis study. Schizophr Bull. 2016;42(2):464–75.PubMedCrossRefGoogle Scholar
  55. 55.
    Bendall S, Hulbert CA, Alvarez-Jimenez M, Allott K, McGorry PD, Jackson HJ. Testing a model of the relationship between childhood sexual abuse and psychosis in a first-episode psychosis group: the role of hallucinations and delusions, posttraumatic intrusions, and selective attention. J Nerv Ment Dis. 2013;201(11):941–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Kocsis-Bogár K, Mészáros V, Perczel-Forintos D. Gender differences in the relationship of childhood trauma and the course of illness in schizophrenia. Compr Psychiatry. 2018;82:84–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Gayer-Anderson C, Fisher HL, Fearon P, Hutchinson G, Morgan K, Dazzan P, et al. Gender differences in the association between childhood physical and sexual abuse, social support and psychosis. Soc Psychiatry Psychiatr Epidemiol. 2015;50(10):1489–500.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Arseneault L, Bowes L, Shakoor S. Bullying victimization in youths and mental health problems: «much ado about nothing»? Psychol Med. 2010;40(5):717–29.PubMedCrossRefGoogle Scholar
  59. 59.
    Kelleher I, Keeley H, Corcoran P, Ramsay H, Wasserman C, Carli V, et al. Childhood trauma and psychosis in a prospective cohort study: cause, effect, and directionality. Am J Psychiatry. 2013;170(7):734–41.PubMedCrossRefGoogle Scholar
  60. 60.
    Mackie CJ, O’Leary-Barrett M, Al-Khudhairy N, Castellanos-Ryan N, Struve M, Topper L, et al. Adolescent bullying, cannabis use and emerging psychotic experiences: a longitudinal general population study. Psychol Med. 2013;43(5):1033–44.PubMedCrossRefGoogle Scholar
  61. 61.
    Broderick PC. Early adolescent gender differences in the use of ruminative and distracting coping strategies. J Early Adolesc. 1998;18(2):173–91.CrossRefGoogle Scholar
  62. 62.
    Nolen-Hoeksema S, Larson J, Grayson C. Explaining the gender difference in depressive symptoms. J Pers Soc Psychol. 1999;77(5):1061–72.PubMedCrossRefGoogle Scholar
  63. 63.
    Fisher HL, Schreier A, Zammit S, Maughan B, Munafò MR, Lewis G, et al. Pathways between childhood victimization and psychosis-like symptoms in the ALSPAC birth cohort. Schizophr Bull. 2013;39(5):1045–55.PubMedCrossRefGoogle Scholar
  64. 64.
    Jockers-Scherübl MC, Wolf T, Radzei N, Schlattmann P, Rentzsch J, Gómez-Carrillo de Castro A, et al. Cannabis induces different cognitive changes in schizophrenic patients and in healthy controls. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(5):1054–63.PubMedCrossRefGoogle Scholar
  65. 65.
    de la Serna E, Mayoral M, Baeza I, Arango C, Andrés P, Bombin I, et al. Cognitive functioning in children and adolescents in their first episode of psychosis: differences between previous cannabis users and nonusers. J Nerv Ment Dis. 2010;198(2):159–62.PubMedCrossRefGoogle Scholar
  66. 66.
    Ruiz-Veguilla M, Moreno-Granados J, Salcedo-Marin MD, Barrigon ML, Blanco-Morales MJ, Igunza E, et al. Sex-specific cognitive abnormalities in early-onset psychosis. Rev Bras Psiquiatr. 2017;39(1):28–35.PubMedCrossRefGoogle Scholar
  67. 67.
    Marsh R, Gerber AJ, Peterson BS. Neuroimaging studies of normal brain development and their relevance for understanding childhood neuropsychiatric disorders. J Am Acad Child Adolesc Psychiatry. 2008;47(11):1233–51.PubMedPubMedCentralCrossRefGoogle Scholar
  68. 68.
    Ayesa-Arriola R, Setién-Suero E, Neergaard KD, Belzunces ÀA, Contreras F, van Haren NEM, et al. Premorbid IQ subgroups in first episode non affective psychosis patients: long-term sex differences in function and neurocognition. Schizophr Res. 2018;197:370–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Goldstein JM, Cherkerzian S, Tsuang MT, Petryshen TL. Sex differences in the genetic risk for schizophrenia: history of the evidence for sex-specific and sex-dependent effects. Am J Med Genet B Neuropsychiatr Genet. 2013;162(7):698–710.CrossRefGoogle Scholar
  70. 70.
    Goldstein JM, Cherkerzian S, Seidman LJ, Petryshen TL, Fitzmaurice G, Tsuang MT, et al. Sex-specific rates of transmission of psychosis in the New England high-risk family study. Schizophr Res. 2011;128(1):150–5.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Neill JC, Kulkarni J. Biological basis of sex differences in psychopharmacology. Berlin: Springer; 2011.CrossRefGoogle Scholar
  72. 72.
    Walder DJ, Holtzman CW, Addington J, Cadenhead K, Tsuang M, Cornblatt B, et al. Sexual dimorphisms and prediction of conversion in the NAPLS psychosis prodrome. Schizophr Res. 2013;144(1):43–50.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Álvaro Andreu
    • 1
  • Maria Juncal Ruiz
    • 2
  • Ernesto José Verdura Vizcaino
    • 1
  • Beatriz Payá-González
    • 3
    Email author
  1. 1.Child and Adolescent Psychiatry DepartmentHospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAMMadridSpain
  2. 2.Hospital SierrallanaSantanderSpain
  3. 3.Child and Adolescent Psychiatry DepartmentHospital Universitario Marques ValdecillaSantanderSpain

Personalised recommendations