CLINICAL HANDBOOK OF SCHIZOPHRENIA

578 VIII. SPECIAL TOPICSalence of drug and alcohol abuse is significantly higher in men. Women in the generalpopulation (and also women with schizophrenia) compared to men show more emotionalreactivity to the stresses of everyday life. They also have higher rates of positive psychoticsymptoms (delusions and hallucinations). These findings agree with what is known aboutthe role of emotional processes in the cognitive biases that lead to positive symptoms.Negative emotional states may contribute to a “psychotic” appraisal of experience, thusprovoking psychotic symptoms. Higher levels of depression, such as those found inwomen with schizophrenia compared to men, may induce biases in logical reasoning thatcontribute to positive symptoms.COURSE AND OUTCOME TRAJECTORYOF ILLNESS IN MEN AND WOMENMen have a poorer short- and medium-term course of schizophrenia than do women.This is true whether one looks at relapse rate, rehospitalization, time to relapse, durationof hospital admission, response to treatment, or social adjustment and occupational functioning.Prison rates and suicide rates are also lower in women. In a review of short- (2–5years) and medium- (5–10 years) term follow-up studies, Angermeyer, Kuhn, andGoldstein (1990) found that about half of the studies indicated a more favorable outcomein women. The other half found no sex differences. It is the social course of the illness,rather than symptom scores, that is significantly associated with gender. Women’s generaltendencies toward prosocial behavior, cooperativeness, and compliance might be a keyinfluence here. Long-term prognosis (13–40 years), however, appears to be the same forwomen and men. The improved earlier course for women is perhaps a result of a laterstart to their illness; the seeming deterioration after menopause may be secondary to theloss of the neuroprotective effects of estrogens or to the problems that women generallyexperience when they grow old: loneliness, poverty, age-related health problems, loss ofsocial supports.SOCIAL ROLE EFFECTIVENESSFemale patients with schizophrenia, more often than men, are able to enter into and maintainsocial roles. For instance, at first occurrence of illness, roughly one-third of women aremarried, compared to less than one-fifth of men. Comparable figures for the general populationshow that three-fourths of women and over one-half of men are married. With respectto parenting roles, approximately half of all women with schizophrenia have children.However, because blunted affect and paranoid thinking can severely impair maternalcompetence, women with schizophrenia are frequently unable to rear their children. Aboutone-third lose custody of their children to family members, ex-partners, foster care, or toadoption. Single motherhood adds to the stresses of mothers with schizophrenia, and this isusually exacerbated by partner violence, poverty, and substance abuse.TREATMENT RESPONSEWomen appear to require lower doses of antipsychotic drugs than do men to achieveequal improvement. This may be due to the attainment of higher blood levels (partly