An overview on gender, personality and mental health

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1 Personality and Mental Health 1: (2007) Published online in Wiley InterScience ( An overview on gender, personality and mental health JOEL PARIS, Department of Psychiatry, McGill University and SMBD-Jewish General Hospital, Montreal, Québec, Canada ABSTRACT Personality traits are influenced by gender, and these differences are unlikely to be artefacts. Gender effects on traits also shape differences in the prevalence of common mental disorders, so that internalizing disorders are more common in females, while externalizing disorders are more common in males. Finally, gender effects influence the prevalence of specifi c personality disorders. These differences have clinical implications. Copyright 2007 John Wiley & Sons, Ltd. Gender differences in personality traits Gender differences in personality are real, appear early in life and are stable over time. Over 30 years ago, Maccoby and Jacklin (1974), reviewing a large body of research on temperament in children, noted consistent fi ndi ngs showing that boys tend to be more assertive and dominant while girls tend to be more anxious. A meta-analysis of the literature in adults (Feingold, 1994) elicited quite similar fi ndi ngs: ma le s were more assertive and have higher self-esteem, while females were higher in extraversion, anxiety, trust and nurturance. However, not every personality trait showed gender effects; there were no differences in social anxiety, impulsiveness, activity, reflectiveness, locus of control and orderliness. In a recent study examining this issue from the perspective of the Five- Factor Model of Personality in a large community sample, Goodwin and Gotlib (2004) found that neuroticism, agreeableness, conscientiousness and extraversion are all higher in women, while openness to experience was greater in men. Although socialization theories have been influential in recent decades (Renzetti & Curran, 2002), gender differences in personality are also rooted in biology. While these effects can be either exaggerated or reduced by cultural forces, Costa, Terracciano, and McCrae (2001) found that similar gender effects on traits are seen in cultures all over the world. This shows that gender differences on personality, while they may be reinforced by socialization, are not socially constructed. Males and females have many differences in brain function (Kimura, 2000): males are superior on performance on certain spatial tasks, throwing accuracy and mathematical reasoning tasks, while females are superior in verbal memory and recall of object locations. At the same time, there are numerous and reliable anatomical brain differences that differentiate men and women, as well as differences in systems connecting the two

2 Gender, personality and mental health 15 hemispheres (Kimura, 2000). Like physical differences between males and females, temperament and personality traits are influenced by sex hormones, and there is a particularly strong relationship between testosterone and aggression (Baghaei et al., 2003). One would expect all these differences to be reflected in personality traits, which have been shown to have a large biological component. Thus, a wide body of behavioural genetic data (Plomin, DeFries, McClearn, & Rutter, 2000) has shown that half of the variance in personality traits is heritable. To examine the relationship between gender, heritability and traits, Jang, Livesley, and Vernon (1998) conducted sex-by-genotype analyses of the Dimensional Assessment of Personality Pathology in a large twin sample. The results showed that genetic influences underlay gender differences affecting 14 out of 18 trait dimensions, and that heritable influences were gender specific, whereas the influence of the environment was the same in both genders across all dimensions. A large body of literature (Harris, 2006; Reiss, Hetherington, & Plomin, 2000; Rowe, 1994) has shown that temperamental differences drive parenting practices (as opposed to the older view that parenting determines the structure of personality). Thus, differential treatment of boys and girls may be as much related to gender differences in temperament as to parental biases. The relationship of the quality of parenting to gender differences in personality is less clear, and there is little evidence that personality differences between boys or girls reflect different qualities of care. For example, in a community sample using the Five-Factor Model, Reti et al. (2002) found effects of low parental care and high parental intrusiveness, which were associated with high neuroticism, low conscientiousness, low self-directedness and high harm avoidance, but there were no significant gender effects. Nonetheless, gender effects on personality likely reflect both genetic and environmental influences. But individual variations within each gender are large, leading to great overlap. We need to be careful to avoid stereotyping men and women, since even when group differences for personality traits are considerable, individual women can have traits more common in men, and individual men can have traits more common in women. The relationship of traits and symptoms Psychological symptoms are strongly influenced by personality trait profiles (Krueger, Caspi, Moffitt, Silva, & McGee, 1996). There are a number of ways to describe these relationships, but a system that groups symptoms into externalizing and internalizing dimensions has earned wide validation, both in childhood (Achenbach & McConaughy, 1997) and in adulthood (Krueger, 1999). Externalizing symptoms and behaviours refer to a tendency to deal with problems through action, while internalizing symptoms and behaviours refer to a tendency to respond to problems with inner suffering. Thus, substance abuse and criminality are related to an externalizing dimension, while depression and anxiety are related to an internalizing dimension. This dichotomy does not account for all psychopathology (particularly cognitive symptoms in the psychoses), but is relevant to understanding common mental disorders. Krueger (1999) showed that one can factor analyse most of the symptoms listed as criteria in Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) into these two dimensions. While more fi ne-grained systems such as the Five-Factor Model (Costa & Widiger, 2001) have been widely used in research to classify personality traits, this broader model has advantages for considering gender effects. During childhood, symptoms that correspond to an internalizing dimension are more common in girls, while those that correspond to an externalizing dimension are more common in boys (Achenbach & McConaughy, 1997). These differences persist over time, leading to a male predominance in adult externalizing disorders and to a female predominance in adult internalizing disorders (Crick & Zahn-Waxler, 2003).

3 16 Paris Internalizing disorders Large-scale epidemiological surveys consistently show that depression is more common in women (Weissman & Klerman, 1985), a gender difference that is found in countries around the world (Culbertson, 1997; Ustun, 2001). While some researchers (Bogner & Gallo, 2004) have suggested that these fi ndings might be an artefact of selfreport (i.e., men being less willing to describe depressive symptoms), this is one of the most robust fi ndi ngs in all of psychiatric epidemiology. Moreover, these gender differences appear early in development. Kessler (2003), drawing on data from the National Comorbidity Survey, noted that the higher prevalence of depression among adult women than in men was due to higher risk of fi rst onset, not to differential persistence or recurrence. However, a large-scale study of adolescent health (Rushton, Forcier, & Schectman, 2002) found that depression is not only more common in girls, but persists longer. Anxiety disorders are generally more common in women, with the exception of obsessive compulsive disorder (Pigott, 1999). Post-traumatic stress disorder is also more common in women, and this may reflect both biological differences and differences in exposure to environmental stressors (Peirce, Newton, Buckley, & Keane, 2002). It is notable that mood and anxiety disorders are highly comorbid, so that their symptoms may reflect common pathological processes (Goldberg & Goodyer, 2005), associated with an internalizing dimension. A large-scale community study (Kendler, Gatz, Gardner, & Pederse, 2006) demonstrated that depression is consistently related to high levels of the broad personality trait of neuroticism. A related fi nding concerns gender differences in suicidal behaviours and in completed suicide. The higher rates of suicide attempts in women could be related to gender differences in depression (Beautrais, 2001). However, suicide completion is a separate phenomenon, and the higher rate of completed suicide in men reflects the fact that men use more fatal means and are more likely to die on the fi rst attempt (Brezo, Paris, & Turecki, 2006). It is possible that this gender difference also reflects personality, such as an action orientation associated with externalizing behaviours. Externalizing disorders Men have a higher rate of substance abuse, and gender differences are robust across societies around the world (Helzer & Canino, 1992). Chassin, Pitts, & Prost (2002) found that a pattern of heavy and early abuse in adolescence is more common in boys and is strongly related to externalizing traits. While the gap has narrowed somewhat among adolescents over recent years (Greenfield, Manwani, & Nargiso, 2003), it remains prominent. The relation between substance abuse and personality is complex. Comorbidity with personality disorders (PDs) is common (Strand, 2002), but there is no single pattern of traits associated with alcohol and drug abuse some substance abusers are higher in externalizing symptoms while others are higher in internalizing symptoms; different personality traits can be associated with different drugs of choice (O Brien, 2003). While the precursors of criminality are fairly similar in men and women (Messer, Maughan, Quinton, & Taylor, 2004), men are much more likely than women to develop criminal behaviour (Rutter & Smith, 1995). It has been consistently found that antisocial personality and psychopathy are largely male disorders (Black, 1999), and these patients are particularly high in externalizing behaviours. PDs and personality traits PDs can often be understood as dysfunctional exaggerations of normal personality traits (Livesley, Jang, & Vernon, 1998). While some community surveys have found more men with PDs (Coid,

4 Gender, personality and mental health 17 Yang, Tyrer, Roberts, & Ullrich, 2006; Samuels et al., 2002), others have not observed gender differences (Torgersen, Kringlen, & Cramer, 2001). Using the Axis II system, Cluster A disorders (especially schizoid personality) seem to be more frequent in men (Samuels et al., 2002; Torgersen et al., 2001). In Cluster C, fi ndings are not consistent, although one study (Samuels et al., 2002) found that dependent PD was more common in women, while obsessive compulsive personality was more prevalent in men. In Cluster B, the most striking difference is the higher prevalence of antisocial personality in men (Black, 1999), with 80% of cases of antisocial personality being men. The personality trait that underlies antisocial personality disorder (ASPD) has been termed impulsive aggression (Siever & Davis, 1991), a characteristic more commonly found in males. Criminal behaviour often begins in childhood, and early onset conduct disorder is a known precursor of antisocial personality (Robins, 1966). Conduct disorder, in turn, is much more common in boys than in girls (Messer et al., 2004). Conduct disorder begins later in girls than in boys, and produces different behaviours, although it might be diagnosed more frequently in females if diagnostic criteria were rewritten (Zoccolillo, Tremblay, & Vitaro, 1996). Thus the diagnostic criteria for ASPD in the DSM-IV-TR classification (American Psychiatric Association, 2000) determine a gender difference in prevalence, since they require a prior history of conduct disorder (more common in boys), a pattern of criminal behaviour (more frequent in men), aggressiveness (the most consistent of all gender differences in personality), as well as irresponsibility (usually more severe in males.) Borderline personality disorder (BPD) is a mirror image of ASPD in its prevalence by gender. About 80% of patients seen in clinical settings are female (Gunderson, 2001). Although some have suggested this difference could reflect sample bias (Skodol & Bender, 2003), similar gender differences have been found in epidemiological studies (Samuels et al., 2002; Torgersen et al., 2001), but not in all (Coid et al., 2006). The defi nition of BPD (American Psychiatric Association, 2000) rests in part on externalizing symptoms of an impulsive nature that present in different ways in females (e.g., overdoses and self-cutting). However, the defi nition also includes many internalizing symptoms that are more common in women. Thus, the affective instability that characterizes BPD is probably a different phenomenon from the symptoms of mood disorders (Paris, Gunderson, & Weinberg, 2007). Histrionic personality disorder (HPD) has usually been seen as pro-typically female, yet epidemiological studies (Coid et al., 2006; Nestadt et al., 1990; Samuels et al., 2002; Torgersen et al., 2001) have found an equal number of men meeting criteria. Similarly, narcissistic personality disorder (NPD) has been found in equal numbers of men and women in the community (Coid et al., 2006). Similar underlying traits may lead to different behavioural presentations in males and females. For example, ASPD and BPD, as well as HPD and NPD, might be different aspects of the same psychopathological processes, influenced by traits that are more common in males and females (Looper & Paris, 2000). ASPD and BPD certainly have a number of points of overlap: in symptoms, in personality dimensions that underlie their phenomenology, in their mirror-image gender prevalence, in risk factors, in outcome and in response to treatment (Paris, 1997). Ultimately, gender differences in PDs reflect differences in traits (Axelrod, 1999). But diagnostic criteria can provide different weighting for internalizing and externalizing psychopathology (Anderson, Sankis, & Widiger, 2001; Jane, 2001) or describe behavioural patterns that are genderspecific (Cale & Lilienfeld, 2002; Funtowicz & Widiger, 1999). For example, the criteria of ASPD focus on male behaviours such as criminality, while the criteria for BPD focus on affective symptoms that are more likely to be seen in females. Yet the personality traits that underlie these disorders could be similar.

5 18 Paris Clinical implications Gender effects of personality are of theoretical interest, but also have implications for practice. While most patients in child psychiatry are male, a majority of adult patients are female (Gold, 1998). These gender differences reflect differences in the prevalence of common mental disorders, but they also reflect differences in treatment seeking (Goldberg & Goodyer, 2005). Moreover, behind diagnosable disorders lie differences in personality trait profiles, shaping the way psychopathology presents symptomatically. Understanding the effect of gender on personality could be important for establishing alliances, for the conduct of psychotherapy and for ensuring compliance (Compton, Rudisch, Weiss, West, & Kaslow, 2005). An externalizing profile, in which problems are seen as lying outside oneself, produces more difficult problems for most forms of treatment than an internalizing profile, in which patients acknowledge inner suffering. This problem underlies the difficulties that mental health clinicians often have in managing patients with substance abuse or ASPD, and may also help to account for the predominance of mood and anxiety disorders in practice. References Achenbach, T. M., & McConaughy, S. H. (1997). Empirically based assessment of child and adolescent psychopathology: Practical applications (2nd ed.). Thousand Oaks, CA: Sage. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Anderson, K. G., Sankis, L. M., & Widiger, T. A. (2001). Pathology versus statistical infrequency: Potential sources of gender bias in personality disorder criteria. Journal of Nervous and Mental Diseases, 189, Axelrod, S. R. (1999). Understanding sex differences in personality disorders as sex differences in normal personality traits. Dissertation Abstracts International, 60/3-B, Baghaei, F., Rosmond, R., Landen, M., Westberg, L., Hellstrand, M., Holm, G., Eriksson, E., & Bjorntorp, P. (2003). Phenotypic and genotypic characteristics of women in relation to personality traits. International Journal of Behavioral Medicine, 10, Beautrais, A. L. (2001). Suicides and serious suicide attempts: Two populations or one? Psychological Medicine, 31, Black, D. W. (1999). Bad boys, bad men: Confronting antisocial personality. New York: Oxford University Bogner, H. R., & Gallo, J. J. (2004). Are higher rates of depression in women accounted for by differential symptom reporting? Social Psychiatry and Psychiatric Epidemiology, 39, Brezo, J., Paris, J., & Turecki, G. (2006). Personality traits as risk factors for suicidality: A systematic review. Acta Psychiatrica Scandinavica, 113, Cale, E. M., & Lilienfeld, S. O. (2002). Histrionic personality disorder and antisocial personality disorder: Sex-differentiated manifestations of psychopathy? Journal of Personality Disorders, 16, Chassin, L., Pitts, S. C., & Prost, J. (2002). Binge drinking trajectories from adolescence to emerging adulthood in a high-risk sample: Predictors and substance abuse outcomes. Journal of Consulting and Clinical Psychology, 70, Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. (2006). Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry, 188, Compton, M. T., Rudisch, B. E., Weiss, P. S., West, J. C., & Kaslow, N. J. (2005). Predictors of psychiatrist-reported treatment-compliance problems among patients in routine U.S. psychiatric care. Psychiatry Research, 13, Costa, P. T., & Widiger, T. A. (Eds.) (2001). Personality Disorders and the Five Factor Model of Personality (2nd ed.) Washington, DC: American Psychological Association. Costa, P. T., Terracciano, A., & McCrae, R. R. (2001). Gender differences in personality traits across cultures: Robust and surprising fi ndings. Journal of Personality and Social Psychology, 81, Crick, N. R., & Zahn-Waxler, C. (2003). The development of psychopathology in females and males: Current pro gress and future challenges. Development & Psychopathology, 15, Culbertson, F. M. (1997). Depression and gender. An international review. American Psychologist, 52, Feingold, A. (1994). Gender differences in personality: A meta-analysis. Psychological Bulletin, 116, Funtowicz, M. N., & Widiger, T. A. (1999). Sex bias in the diagnosis of personality disorders: An evaluation of the DSM-IV criteria. Journal of Abnormal Psychology, 198,

6 Gender, personality and mental health 19 Gold, J. H. (1998). Gender differences in psychiatric illness and treatments: A critical review. Journal of Nervous & Mental Disease, 186, Goldberg, D., & Goodyer, I. (2005). The origins and course of common mental disorders. London: Taylor and Francis. Goodwin, R. D., & Gotlib, I. H. (2004). Gender differences in depression: The role of personality factors. Psychiatry Research, 126, Greenfield, S. F., Manwani, S. G., & Nargiso, J. E. (2003). Epidemiology of substance use disorders in women. Obstetrics & Gynecology Clinics of North America, 30, Gunderson, J. G. (2001). Borderline Personality Disorder: A Clinical Guide. Washington, D. C.: American Psychiatric Harris, J. R. (2006). No two alike: Human nature and human individuality. New York: Norton. Helzer, J. E., & Canino, G. J. (Eds.) (1992). Alcoholism in North America, Europe, and Asia. New York: Oxford University Jane, J. S. (2001). Gender bias in diagnostic criteria for personality disorders: An item response theory analysis. Dissertation Abstracts International, 62(2-B), Jang, K. L., Livesley, W. J., & Vernon, P. A. (1998). A twin study of genetic and environmental contributions to gender differences in traits delineating personality disorder. European Journal of Personality, 12, Kendler, K. S., Gatz, M., Gardner, C. O., & Pederse, N. L. (2006). Personality and major depression. Archives of General Psychiatry, 63, Kessler, R. C. (2003). Epidemiology of women and depression. Journal of Affective Disorders, 74, Kimura, D. (2000). Sex and cognition. Cambridge, MA: MIT Krueger, R. F. (1999). The structure of common mental disorders. Archives of General Psychiatry, 56, Krueger, R. F., Caspi, A., Moffitt, T. E., Silva, P. A., & McGee, R. (1996). Personality traits are differentially linked to mental disorders: A multitrait-multidiagnosis study of an adolescent birth cohort. Journal of Abnormal Psychology, 105, Livesley, W. J., Jang, K. L., & Vernon, P. A. (1998). Phenotypic and genetic structure of traits delineating personality disorder. Archives of General Psychiatry, 55, Looper, K., & Paris, J. (2000). What are the dimensions underlying cluster B personality disorders? Comprehensive Psychiatry, 41, Maccoby, E., & Jacklin, C. N. (1974). The psychology of sex differences. Stanford, CA: Stanford University Messer, J., Maughan, B., Quinton, D., & Taylor, A. (2004). Precursors and correlates of criminal behaviour in women. Criminal Behaviour & Mental Health, 14, Nestadt, G., Romanovski, A. J., Chahal, R., Merchant, A., Folstein, M. F., Gruenberg, E. M., & McHugh, P. R. (1990). An epidemiological study of histrionic personality disorder. Psychological Medicine, 20, O Brien C. P. (2003). Research advances in the understanding and treatment of addiction. American Journal on Addictions, 12/Suppl. 2, S Paris, J. (1997). Antisocial and borderline personality disorders: Two separate diagnoses or two aspects of the same psychopathology? Comprehensive Psychiatry, 38, Paris, J., Gunderson, J. G., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrem disorder. Comprehensive Psychiatry, 48, Peirce, J. M., Newton, T. L., Buckley, T. C., & Keane, T. M. (2002). Gender and psychophysiology of PTSD. In R. Kimerling, P. Ouimette, & J. Wolfe (Eds.), Gender and PTSD (pp ). New York: Guilford Pigott, T. A. (1999). Gender differences in the epidemiology and treatment of anxiety disorders. Journal of Clinical Psychiatry, 60(Suppl. 18), Plomin, R., DeFries, J. C., McClearn, G. E., & Rutter, M. M. (2000). Behavioral genetics: A primer (3rd ed.). New York: W. H. Freeman. Reiss, D., Hetherington, E. M., & Plomin, R. (2000). The relationship code. Cambridge, MA: Harvard University Renzetti, C. M., & Curran, D. J., (2002). Women, men, and society. Upper Saddle River, NJ: Pearson Education. Reti, I. M., Samuels, J. F., Eaton, W. W., Bienvenu, O. J. III, Costa, P. T., & Nestadt, G. (2002). Influences of parenting on normal personality traits. Psychiatry Research, 111, Robins, L. N. (1966). Deviant children grown up. Baltimore: Williams and Wilkins. Rowe, D. C. (1994). The limits of family infl uence: Genes, experience, and behavior. New York: Guilford. Rushton, J. L., Forcier, M., & Schectman, R. M. (2002). Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. Journal of the American Academy of Child & Adolescent Psychiatry, 41, Rutter, M., & Smith, D. J. (1995): Psychosocial problems in young people. Cambridge, UK: Cambridge University Samuels, J., Eaton, W. W., Bienvenu, J., Clayton, P., Brown, H., Costa, P. T., & Nestadt, G. (2002). Prevalence and correlates of personality disorders in a community sample. British Journal of Psychiatry, 180, Siever, L. J., & Davis. K. (1991). A psychobiological perspective on the personality disorders. American Journal of Psychiatry, 148,

7 20 Paris Skodol, A. E., & Bender, D. S. (2003). Why are women diagnosed borderline more than men? Psychiatric Quarterly, 74, Strand, P. S. (2002). Treating antisocial behavior: A context for substance abuse prevention. Clinical Psychology Review, 22, Torgersen, S., Kringlen, E., & Cramer, V. (2001). The prevalence of personality disorders in a community sample. Archives of General Psychiatry, 58, Ustun, T. B. (2001). The worldwide burden of depression in the 21st century. In Weissman, M. M. (ed.). Treatment of Depression: Bridging the 21 st Century. Washington, DC: American Psychiatric Publishing, Inc. pp Weissman, M. M., & Klerman, G. L. (1985). Gender and depression. Trends Neuroscience, 8, Zoccolillo, M. Tremblay, R., & Vitaro, F. (1996). DSM-III-R and DSM-III criteria for conduct disorder in preadolescent girls: Specific but insensitive. Journal of the American Academy of Child & Adolescent Psychiatry, 35, Address correspondence to: Joel Paris, MD, Professor, Department of Psychiatry, McGill University, and Research Associate, SMBD-Jewish General Hospital, 4333 chemin de la côte ste. Catherine, Montreal, Québec, H3T 1E4, Canada. joel.paris@mcgill.ca