Disentangling heterogeneity of psychosis expression in the general population: Sex-specific moderation effects of environmental risk factors on symptom networks

Linda T. Betz*, Nora Penzel, Marlene Rosen, Kamaldeep Bhui, Rachel Upthegrove, Joseph Kambeitz

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background Psychosis expression in the general population may reflect a behavioral manifestation of the risk for psychotic disorder. It can be conceptualized as an interconnected system of psychotic and affective experiences; a so-called 'symptom network'. Differences in demographics, as well as exposure to adversities and risk factors, may produce substantial heterogeneity in symptom networks, highlighting potential etiological divergence in psychosis risk. Methods To explore this idea in a data-driven way, we employed a novel recursive partitioning approach in the 2007 English National Survey of Psychiatric Morbidity (N = 7242). We sought to identify 'network phenotypes' by explaining heterogeneity in symptom networks through potential moderators, including age, sex, ethnicity, deprivation, childhood abuse, separation from parents, bullying, domestic violence, cannabis use, and alcohol. Results Sex was the primary source of heterogeneity in symptom networks. Additional heterogeneity was explained by interpersonal trauma (childhood abuse and domestic violence) in women and domestic violence, cannabis use, ethnicity in men. Among women, especially those exposed to early interpersonal trauma, an affective loading within psychosis may have distinct relevance. Men, particularly those from minority ethnic groups, demonstrated a strong network connection between hallucinatory experiences and persecutory ideation. Conclusion Symptom networks of psychosis expression in the general population are highly heterogeneous. The structure of symptom networks seems to reflect distinct sex-related adversities, etiologies, and mechanisms of symptom-expression. Disentangling the complex interplay of sex, minority ethnic group status, and other risk factors may help optimize early intervention and prevention strategies in psychosis.

Original languageEnglish
Pages (from-to)1860-1869
Number of pages10
JournalPsychological Medicine
Issue number5
Early online date25 Aug 2021
Publication statusPublished - Apr 2023

Bibliographical note

Publisher Copyright:
Copyright © The Author(s), 2021. Published by Cambridge University Press.


  • affective pathway to psychosis
  • environmental exposure
  • general population
  • Network analysis
  • psychopathology
  • sex differences

ASJC Scopus subject areas

  • Applied Psychology
  • Psychiatry and Mental health


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