Child and Adolescent Mental Health Volume **, No. *, 2023, pp. **–** doi:10.1111/camh.12674
Psychotic-like experiences and adverse life events in
young people. Does gender matter?
Samuel Adjorlolo1,2 , Victoria Awortwe3, Adote Anum4, Keng-Yen Huang5,6 &
Daniel Mamah7
1Department of Mental Health, School of Nursing andMidwifery, College of Health Sciences, University of Ghana, Accra,
Ghana
2Research and Grant Institute of Ghana, Accra, Ghana
3Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
4Department of Psychology, School of Social Sciences, College of Humanities, University of Ghana, Accra, Ghana
5Department of Population Health, New York University School of Medicine, New York, NY, USA
6Child and Adolescent Psychiatry, New York University School of Medicine, New York, NY, USA
7Department of Psychiatry, Washington University Medical School, St. Louis, MO, USA
Background: Psychotic-like experiences (PLEs) and adverse life events (ALEs) are highly prevalent in sub-
Saharan Africa where gendered practices are also common. There is, however, a paucity of data on how the
relationship between PLEs and life adversities is influenced by gender. The current study addressed this gap.
Method: Data were collected from 1886 school-based young people (1174 females) in Ghana, West Africa
using a cross-sectional survey methodology and analyzed using Chi-square, independent t-test, Pearson corre-
lation, and multivariate regression. Results: The results showed that victimization experiences, school stress
and having a family member with mental illness were significantly associated with PLEs in both males and
females. In contrast, substance misuse and experiences of head trauma correlated significantly with PLEs in
females only. Conclusion: Life adversities constitute major risk factors for PLEs among school-based young
people in Ghana, who could benefit from gender neutral and gender-sensitive intervention programming to
remediate the effects of life adversities on PLEs.
Key Practitioner Message
• The experiences of psychotic-like symptoms and life adversities are common among school-going children
and adolescents. However, there is limited clarity regarding whether the relationship between ALEs and
PLEs is invariant across gender.
• Experiences relating to victimization, school stress, and mental illness in family predicted PLEs in males and
females, while lifetime substance misuse and trauma to head predicted PLEs only in females.
• School authorities and mental health practitioners should institute systematic screening of adolescents for
life and PLEs adversities in both males and females.
Keywords: Adolescents; adverse life experiences; psychosis; Africa; Ghana
Introduction misuse, mood problems, and anxiety disorders (Adjor-
lolo & Anum, 2021; Fusar-Poli et al., 2012). The ten-
Psychotic-like experiences (PLEs) refers to the manifes- dency for PLEs to convert to psychosis and the gross
tation of the symptoms of psychosis such as hallucina- functional impairment associated with PLEs have served
tions, delusions, and avolition that are below the clinical to motivate several research types and intervention ini-
threshold to warrant a diagnosis of psychosis. Owing to tiatives for decades (Soneson et al., 2020; Staines
maturational and developmental responses, young peo- et al., 2022).
ple tend to experience PLEs, relative to older population Scholarly interest in PLEs from sub-Saharan Africa
(Staines et al., 2022). While majority tend to outgrow (SSA) has emerged, with existing data produced mostly
these experiences; however, a few individuals, the so- from Kenya (Mamah et al., 2012, 2013, 2016; Ndetei
called clinical high risk, tend to be diagnosed with psy- et al., 2012; Owoso et al., 2018), Ghana (Adjorlolo &
chotic disorders later in life at a rate higher than that of Anum, 2021; Adjorlolo, Anum, & Adjorlolo, 2021), and
the general population (Adewuya, Oladipo, Imarah, Nigeria (Adewuya et al., 2022; Okewole et al., 2015).
Asmal, & Emsley, 2022; Fusar-Poli et al., 2012). Individ- Altogether, evidence suggest a high prevalence rate of
uals with PLEs are at increased risk of expressing behav- PLEs (i.e. as high as 45%) among adolescents and young
ioral maladies such as suicidal tendencies, substance adults in SSA (Adjorlolo & Setordzi, 2021). Cross-

 2023 Association for Child and Adolescent Mental Health.
2 Samuel Adjorlolo et al. Child Adolesc Ment Health 2023; *(*): **–**
country studies have found evidence that further sug- females may respond differently to the same set of
gests that PLEs are highly prevalent in SSA, relative to adverse events based on their inherent biological and
western countries, with exceptions (see McGrath sociocultural vulnerabilities. For example, females are
et al., 2015). For example, data from 256,445 partici- reportedly endowed with a ruminative response style
pants from across 52 countries revealed that, the age- and higher levels of the affiliative hormone oxytocin that
sex standardized lifetime PLEs prevalence rate for lower- potentiate the development of internalizing behaviors
income countries was 12.9%, compared with 8.8% in such as PLEs (Harkness et al., 2010). Males, on the other
high-income countries (Nuevo et al., 2012). Among the hand, are exposed to increased brain gene expression
countries from lower-income regions, Ghana registered that precipitate the development of schizophrenia (Chen,
the lowest prevalence rate (5.0%), whereas Burkina Faso Cao, Meyer-Lindenberg, & Schwarz, 2018). Sociocultur-
ranked highest (23.6%). In another cross-country study, ally, substance abuse practices among males in most
the highest prevalence of PLEs (64.9%–99.5%) was SSA countries, including Ghana, are largely tolerated,
found among participants from Ghana, the only African whereas females who use substances are seen as devi-
country involved in the survey, compared with 37%– ants, uncivilized, and uncultured (Nketiah-Amponsah,
93.5% in the United States (Wusten et al., 2018). Afful-Mensah, & Ampaw, 2018). This cultural-
To contribute to the emerging literature on PLEs in sponsored discriminatory practices can negatively affect
SSA, the current study investigated the nexus between the disclosure and help-seeking behaviors among
adverse life events (ALEs) and PLEs within a gendered females, a development that can culminate into devas-
framework. The study was motivated by the high pre- tating and long-term incremental effect of substance
ponderance of ALEs in SSA and the prominence of gen- misuse for females, perhapsmore thanmales.
dered behavioral pattern, which is often rooted in Unfortunately, research efforts explicating gender dif-
socialization processes in several SSA countries, includ- ferences in PLEs have tended to yield inconsistent find-
ing Ghana. The study also responded to recent calls for ings. While some studies found that females endorsed
researchers to adopt a gendered lens to explicate psy- more PLEs compared to their male counterparts, other
chopathological behaviors in SSA (Adjorlolo, Adu-Poku, results revealed that males reported more PLEs than
Andoh-Arthur, Botchway, & Mlyakado, 2017; Adjorlolo, females (Stainton et al., 2021). Studies focusing on spe-
Anum, & Huang, 2022). cific domains of PLEs show that males and females
Operationalized as actual or perceived threat to an appear to endorse different aspects of PLEs. For exam-
individual’s physical or psychological well-being (Rich- ples, females endorsed hallucinations and persecutory
ardson, Carr, Netuveli, & Sacker, 2020), ALEs have been ideation domains of positive PLEs more than males
found to contribute to PLEs among young people in SSA. (Ronald et al., 2014; Scott et al., 2008). The evidence
Among Kenyan youth, Ndetei et al. (2012) found that base in SSA is also uncertain due largely to limited stud-
80% of the participants who endorsed one or more psy- ies although initial studies involving Ghanaian (Adjorlolo
chotic symptoms had a history of substance abuse. In a & Anum, 2021) and Kenyan adolescents (Mamah,
similar study from Kenya, adversities originating from Mutiso, & Ndetei, 2021) found no gender difference,
the family such as relationship difficulties, death, poor whereas another study from Kenyan found PLEs to be
health status, and separation correlated significantly more common inmales (Ndetei et al., 2012).
with PLEs (Mamah et al., 2016). Similar findings have
emerged from data collected from senior high school stu- The present study
dents in Nigeria, with 53% of the participants with pro- Decades of research, situated in the stress vulnerability
dromal symptoms of psychosis reporting a lifetime models, have suggested that exposure to ALEs is a major
experience of adverse events, including bullying and risk factor for psychopathological behaviors in children
alcohol use (Okewole et al., 2015). In a recent study from and adolescents (Tiet et al., 1998). This has largely been
Ghana, Adjorlolo and Anum (2021) found that adoles- supported by earlier studies from SSA that reported sig-
cents designated as clinical high-risk, based on their nificant impact of ALEs on PLEs (e.g. Mamah
PLEs profiles, had a history of substance abuse. et al., 2016). Similarly, gender differences in the expres-
The foregoing notwithstanding, there is limited clarity sion of psychotic symptoms are an important area of
regarding whether the relationship between ALEs and investigation; however, the evidence base is weak owing
PLEs is invariant across gender. That is, there is a pau- to the contradictory and inconsistent results reported in
city of empirical data on whether the nature of the rela- Western countries (Stainton et al., 2021) and the limited
tionship between ALEs and PLEs is the same or different evidence base in SSA. The focus on gender is of interest
for males and females. This observation invokes discus- due to the age-long debate regarding whether gender sig-
sions about exposure and response to adverse events by nificantly influence mental health outcomes as well as
males and females. Indeed, both genders may be recent calls for a gendered framework to understand
exposed to the same or different set of adverse events. psychopathological behaviors in SSA (Adjorlolo
This was demonstrated by Adjorlolo et al. (2022) in their et al., 2017, 2022). As stated previously, males and
study with young people from Ghana in which they females may be similar or differ in their exposure to life
reported that substance misuse and head trauma expe- adversities, but how this could impact their mental well-
riences were significantly elevated in males, relative to being has been inconclusive. In the dataset analyzed for
females. In contrast, the authors found that neighbor- this paper, we reported elsewhere (Adjorlolo et al., 2022)
hood stress, exposure to victimization, school stress, that males significantly abused substances (22.3% vs.
and adversities due to the presence of mental illness in 13.5%) and experienced head trauma (36.3% vs. 31.7%)
the family were experienced equally by males and more than females (p < .05). There was no gender differ-
females. Critical to the discussion is how individuals ence in victimization experience, having a family mem-
respond to adversities. More importantly, males and ber with mental illness and school stress. However, it is

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doi:10.1111/camh.12674 Psychosis and adverse events 3
not clear whether the differences and similarities in the negative subscales, respectively. The CAPE’s positive subscale
experience of life adversities across gender have any comprised four subscales (e.g. persecutory ideation and self-
influence on the expression of subthreshold psychotic referential thinking), whereas the negative subscale has a tri-
partite structure (e.g. social withdrawal and avolition) (Barra-
symptoms. Besides, previous studies have focused over- gan et al., 2011; Mark & Toulopoulou, 2016). Among Ghanaian
whelmingly on positive PLEs with little attention to nega- adolescents, the CAPE has demonstrated evidence for dimen-
tive PLEs (Adjorlolo et al., 2021; Adjorlolo & sional representation of psychotic experiences (Adjorlolo
Anum, 2021; Adjorlolo & Setordzi, 2021). Meanwhile, et al., 2021). In the current study, Cronbach’s alphas of .73 and
negative symptoms constitute essential features of psy- .80 were recorded for the positive and negative subscales,
chosis, accounting for a significant percentage of the respectively.
long-term disability and poor functional outcomes
reported among persons with psychotic disorders (Cor- Data analyses
rell & Schooler, 2020). The foregoing calls for an Data were analyzed using SPSS version 26 (IBM Corp), with a
increased focus on negative PLEs in psychosis research. two-tailed statistical significance set at 0.05. Gender differences
in ALEs and PLEs were examined using Chi-square analysis (for
Taken together, themajor caveat in the literature, partic- categorical variables) and independent t-tests (for continuous
ularly from SSA, relates to whether the relationship variables). Pearson correlation was used to examine the associa-
between ALEs and negative and positive PLEs is invari- tion between the positive and negative domains of PLEs. Lastly,
ant across gender. To address this gap, the study investi- multiple linear regression, controlling for demographic con-
gated gender difference in the relationship between ALEs founders, was used to examine the association between ALEs
and PLEs among young people in Ghana, a SSA country. and PLEs. The analyses were conducted separately for boys and
girls.
Method Results
Design and data collection procedure Demographic characteristics of participants
The study design has been reported elsewhere (Adjorlolo As summarized in Table S1, a total of 1886 students par-
et al., 2022). Briefly, data were collected from senior high school
(SHS) students who have spent at least 12 years of education in ticipated in the study, comprising 62% girls (n = 1174).
Ghana using a cross-sectional survey. English is the official lan- About 55% of the participants had at most 3 siblings,
guage of instruction at the various levels of education in Ghana. and 42.8% performed physical activity lasting for more
The schools included in the study were recruited from rural or than 10 minutes for 1–3 days in a week. Gender did not
peri-urban areas where socialization practices and activities are exert a statistically significant difference on the demo-
centered predominantly on gender. The rural areas directly con- graphic variables except for age, with boys more likely to
trast urban areas/cities where acculturation and economic
struggles have largely changed/diminished gendered behav- be at least 19 years old (p < .001).
ioral tendencies. Over 90% of the students came from the In terms PLEs and gender, it was observed that girls
administrative areas in which the schools were located. The endorsed significantly more persecutory ideation and
selected schools were mixed in terms of gender (i.e. comprise avolition experiences more than boys (all ps < .05). In
males and females), giving us the opportunity to investigate gen- contrast, boys registered significantly more grandiose
der differences in ALEs and PLEs. Questionnaires were admin- thinking and self-referential experiences than girls (all
istered to the participants in their respective classes after
ethical issues were discussed. Only those who consented to par- ps < .05).
ticipate in the study were handed a pack of questionnaires.
Once completed, the questionnaires were handed over to the Correlations among the PLEs domains
research team in each class. The Noguchi Memorial Institute for The results of the association between the PLES
Medical Research Institutional Review Board of the University domains were summarized in Table S2. Across the gen-
of Ghana granted ethical approval for the study (NMIMR-IRB ders, significant associations were observed between the
CPN 012/19-20). PLEs domains, except for avolition and grandiose think-
ing for males. The direction of the correlations is similar
Study measures for both males and females. The magnitude of the corre-
Adverse life experiences. Seven adverse events culled from lations also appears similar across the genders. For
personal, home, and community/neighborhood domains were
included as follow: life time substance use behavior (Have you example, the correlation between hallucination and per-
ever smoked or used alcohol?), traumatic experiences (I was secutory ideation in males (r = .39) and females (r = .40)
involved in an accident or someone hit my head with an object or are similar. Likewise, the relationships between avolition
an object fell on my head), violence victimization (How often you and persecutory ideation for males (r = .33) and females
been physically attacked or beaten in the last 12 months), (r = .34) as well as self-referential thinking and social
school-level stress (How much stress do you usually feel withdrawal domains of negative PLEs for males (r = .18)
because of school activities such as attending classes?), disorga-
nized neighborhood (People in my neighborhood do not respect and females (r = .17) are similar.
rules and laws; People do not care about what goes on in the
neighborhood), and family history of mental disorders (Do you Association between adverse life experiences and
know a relative or family member who suffers from mental ill- psychotic-like symptoms
ness?). The responses to the items were mostly categorical (i.e. The results of the association between ALEs and PLEs
Yes or No). To study dose effect, a summary score was also cre- are summarized in Table S3. Controlling for demo-
ated for analysis. graphic confounders, the study found evidence for gen-
Community Assessment of Psychic Experiences-CAPE (Stefa-
nis et al., 2004) was used to assess for psychotic-like experi- der similarities and differences in the association
ences (PLEs). The CAPE measures both positive (20 items) and between ALEs and psychotic-like symptoms. Victimiza-
negative (14 items) PLEs which are rated using a four-point tion experiences exerted statistically significant effect on
Likert scale ranging from 0 (never) to 3 (nearly always), with positive and negative PLEs, predicting the following sub-
total scores ranging from 0 to 60 and 0 to 42 for positive and domains in both males and females: persecutory

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4 Samuel Adjorlolo et al. Child Adolesc Ment Health 2023; *(*): **–**
ideation (b = .92 vs. .81) hallucinatory experiences overwhelmingly on positive psychotic symptoms, our
(b = 1.46 vs. 1.61), affective flattening (b = .54 vs. .44), study has broadened the discussion by focusing on both
and avolition (b = 1.30 vs. 1.40). Among females, victimi- negative and positive psychotic experiences, taking into
zation experiences were associated with social with- consideration gender. We found evidence for both gender
drawal (b = .73), whereas among males, it was similarities and differences in the relationship between
associated with self-referential thinking (b = .35). ALEs and PLEs. First, it was observed that, males and
Lifetime use of substance such as alcohol was signifi- females who have been victimized and reported high
cantly associated with persecutory ideation experiences school-level stress were significantly more likely to expe-
in both males (b = .84) and females (b = .74), whereas rience both negative and positive psychosis symptoms.
significant relationships were observed for hallucinatory Likewise, the effect ofmental illness in the family on PLEs
experiences (b = 1.29), affective flattening (b = .38), and was prominent, predicting the experience of negative and
volition (b = .1.29) but only in females. Relatedly, males positive psychosis symptoms in males and in females.
and females who experienced high school stress were This observation is largely consistent with Fekadu,
more likely to endorse hallucinatory (b = 1.10 vs. 1.40) Mihiretu, Craig, and Fekadu (2019) who in their review
and avolition (b = .66 vs. 1.49) domains of positive and noted a multidimensional impact of mental illness on
negative PLEs, respectively. Among females, high school familymembers’ (e.g. parents, children, and adolescents)
stress was significantly associated with the experiences psychological, mental, and physical well-being. Although
of persecutory ideation (b = .40) and social withdrawal the exact mechanism underpinning this finding was not
(b = .43). Lastly, whereas having a family member with explored in this study, it is hypothesized that adolescents
mental illness predicted hallucinatory experiences are likely to perceive mental illness in the family as
across the genders, it was significantly associated with stressful, either because of the frequent interactions with
persecutory ideation (b = .45) in females only. family members with mental illness or the negative
In the dose analysis, generally, we found support that expressions bymembers in the neighborhood or commu-
higher number of ALEs was associated with higher posi- nities due to the high stigma associated with mental ill-
tive and negative psychosis symptoms for male and ness (Fekadu et al., 2019; Santos & Cardoso, 2015). The
female, with exception for grandiose (no association for finding similarly highlights genetic susceptibility tomen-
both male and female) and affective flattening (no associ- tal illness such that participants whose family members
ation for male only). have mental illness are also prone to developing mental
disorders, hence the high endorsement of PLEs.
Discussions In terms of gender difference, females with a history of
substance misuse and trauma to the head have elevated
The current study contributed to the emerging literature risk for PLEs. This relationship was not observed for
in SSA regarding the association between life adversities males, although substance misuse and head trauma
and the experience of subliminal psychotic symptoms in experiences were very common among boys owing to bio-
males and females. First, the study found evidence for logical predisposition (e.g. high testosterone) that
the co-occurrence of positive and negative PLEs for both increase risky behaviors and aggression (Van Bokhoven
males and females. The gender invariance in the similar- et al., 2006). Moreover, as discussed previously, histori-
ity of the magnitude and direction of the co-occurrence cally, substance misuse has been associated with the
of negative and positive PLEs reported in this study sug- male gender (Opland,Winters, & Stinchfield, 1995;Wha-
gests that males and females have similar probability of ley, Hayes, & Smith, 2016). Although Ghanaian cultures
developing schizophrenia/other psychotic spectrum dis- mostly prohibit substance use among adolescents
orders and functional impairment in later life should (Nketiah-Amponsah et al., 2018), boys who use sub-
they experience both negative and positive psychotic stance are treated quite leniently than girlswhose actions
experiences. This deduction is consistent with the find- are generally seen to deviate from cultural norms and
ings of a previous study involving 4914 Israel-born indi- gender expectation. This could prevent adolescent girls
viduals aged 25–34 years where it was shown that the from receiving help, thereby increasing the likelihood
risk for schizophrenia later in life was significantly that the long-term and incremental effect of substance
higher among participants with co-occurrence of posi- misuse could be devastating for girls, perhapsmore than
tive and negative psychotic symptoms (Werbeloff boys, including increasing their risk for PLEs. Second,
et al., 2015). In a related study, co-occurrence of positive given that the above ALEs do not occur frequently in girls,
and negative PLEs increased the risk for functional we hypothesized that girls are more likely to have a lower
impairment adolescents and young adults (Dominguez, threshold for their effects which in this studywas PLEs.
Saka, Lieb, Wittchen, & van Os, 2010).
Research has theorized that exposure to life adversi- Implications for screening and early interventions
ties has the tendency to increase emotional reactivity in school settings
that can potentiate psychotic symptoms (Seidu School settings are attractive for promoting adolescent
et al., 2020). Studies conducted in high-income coun- mental health mainly because a high proportion of men-
tries have provided initial support for the above observa- tal health issues appear first and foremost among
tion by noting that victimization and stress exacerbate young people, majority of whom are in school where
the insidious onset of PLEs among adolescents of the they spend a significant amount of their time. The
general population (DeVylder et al., 2016; Mackie, school environment in SSA is still collating relevant
Castellanos-Ryan, & Conrod, 2011). Similar observa- research to inform measures to deliver school mental
tions have been made by emerging studies from SSA health services. The study findings have added to the
(Adjorlolo & Anum, 2021; Mamah et al., 2016; Okewole existing evidence to help support school mental health
et al., 2015). While previous studies have focused intervention and health promotion programming in

 2023 Association for Child and Adolescent Mental Health.
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doi:10.1111/camh.12674 Psychosis and adverse events 5
Ghana. Because of the increased morbidity associated head traumatic experiences would benefit females more
with the presence of co-occurring symptoms, an inte- in terms of reducing their experiences of PLEs. In con-
grated screening that comprise both negative and posi- trast, both males and females would benefit from mea-
tive PLEs measures should be adopted for both males sures to reduce school stress, victimization experiences,
and females. Granting attention to negative PLEs is and stresses associated with having a family member
important because it is a central feature in psychotic with mental illness. This understanding is equally
disorders but also other mental health disorders important in screening for ALEs and PLEs among males
(Andreasen, 1987; Lyne et al., 2012). This could help and females.
identify individuals at risk not only for psychotic disor-
ders but also other mental disorders. Screening for PLEs Acknowledgements
should also incorporate assessment for experiences of
life adversities owing to their preponderance in Ghana The authors have declared that they have no competing or
and more importantly because of their profound effects potential conflicts of interest.
on PLEs. Both males and females should be screened
for school-level stress, victimization experiences and a Ethical information
history of family member with mental illness. Those who
scored high on these ALEs could be screened for both The Noguchi Memorial Institute for Medical Research
positive and negative PLEs to inform early intervention Institutional Review Board of the University of Ghana
decision-making and planning. For example, school granted ethical approval for the study (NMIMR-IRB CPN
stress, family member with mental illness, and victimi- 012/19-20).
zation experiences were significantly associated with
hallucinatory experiences in this study. Thus, interven-
tions targeting hallucinatory experiences should aim to Correspondence
address multiplicity of ALEs affecting both males and Samuel Adjorlolo, Department of Mental Health, School
females. The study found that females who scored high of Nursing and Midwifery, College of Health Sciences,
on head trauma experiences and substance misuse his- University of Ghana, P. O. Box LG 43, Legon, Accra,
tories have elevated risk for experiencing both negative Ghana; Email: sadjorlolo@ug.edu.gh
and positive PLEs. Therefore, a gender-sensitive screen-
ing for ALEs should target head trauma experiences and
substance misuse histories in females.
The study is limited by the adoption of cross-sectional, Supporting information
retrospective design and a self-report methodology, Additional Supporting Information may be found in the online
coupled with the possibility for recall bias and inaccu- version of this article:
rate (under or over) reporting of experiences. The use of
single items for complex experiences could also be limit- Table S1. Study sample & descriptive results.
ing, just as the ndings could not be extended to young Table S2. Correlations among mental health and suicidalfi
persons with dissimilar background from those who par- ideationmeasures (by gender).
Table S3. Association between adverse life experience and
ticipated in the study. Notwithstanding these limita- psychosis symptom outcomes (by gender).
tions, the evidence generated by the study would benefit
discourse on school mental health in Ghana and other
SSA countries, while providing the foundation for addi- References
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one hand, males and females’ endorsement of psychotic- experiences and mental health of adolescents in Ghana: A
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Youth, 27, 444–456.
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somewhat gender neutral and gender-sensitive risk pro- directions. Cogent Psychology, 8, 1949173.
filing and intervention programming based on the Andreasen, N.C. (1987). The concept of negative symptoms:
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6 Samuel Adjorlolo et al. Child Adolesc Ment Health 2023; *(*): **–**
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