Definition of flat affect3/2/2024 9 Moreover, women with schizophrenia usually have fewer cognitive symptoms than men. The flat affect and negative symptoms that characterize men with schizophrenia may not be present in women. 8 Thus, the adolescent presentation of schizophrenia in women may be less clinically obvious because women can mask early schizophrenia with appropriate affect and relatively easy therapeutic engagement. Women with schizophrenia tend to be more socially adept than their male peers, perhaps because they socially mature earlier than men and because their psychotic symptoms often begin at a later age. One hypothesis is that a first episode in middle age predominantly relates to the social stressors that women experience at this time ( Table). It has been suggested that the onset of psychotic symptoms in middle-aged women may have a different etiology than onset that occurs in young adulthood. 3 This hypothesis is consistent with the observation that schizophrenia symptoms can be exacerbated during other times of estrogen withdrawal not only at perimenopause, 4 but also postpartum 5 and during the premenstrual phase of the menstrual cycle. In women, a second peak of schizophrenia onset occurs around the time of menopause, 2 which has been attributed to the decline of estrogen levels as menopause approaches. 1 The older age of onset found in women is partially explained by the fact that many large studies include a wide range of ages, sometimes extending into older age. The first occurrence of the symptoms and behaviors that conform with the currently accepted definition of schizophrenia occur, on average, several years earlier in men than they do in women. The most important differentiating factors are the age of onset, symptom differences, response to antipsychotic medications, parenting responsibilities, and care during the menopausal transition. Several aspects of schizophrenia differ considerably between men and women and influence treatment strategies.
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