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. Author manuscript; available in PMC: 2026 Apr 1.
Published in final edited form as: J Psychopathol Clin Sci. 2025 Mar 13;134(3):251–261. doi: 10.1037/abn0000971

Personality in Psychosis Decades after Onset: Tests of Models of the Relations between Psychopathology and Personality

Elizabeth A Martin 1, Jennifer M Blank 1, Katherine G Jonas 2, Wenxuan Lian 3, Roman Kotov 2
PMCID: PMC11949700  NIHMSID: NIHMS2060771  PMID: 40080555

Abstract

Models have been put forth to describe relations between psychopathology and personality. However, the relation in individuals with psychotic disorders is unclear. As a test of models of psychopathology-personality in psychosis, the current study included 239 individuals, each with one of four psychotic disorders—schizophrenia (SZ), bipolar disorder with psychotic features (BPp), major depressive disorder with psychotic features (MDDp), and substance-induced psychosis (SIP)—and compared their personality to a never-psychotic sample (n=257). In support of the complication + scar model, we found all diagnostic groups were significantly higher on neuroticism and detachment, and most were higher on mistrust and eccentric perceptions than the never-psychotic group (average Cohen’s d=|.83| across all personality measures). Also compared to the never-psychotic group, SZ was lower on extraversion, agreeableness, and conscientiousness; MDDp was lower on extraversion and conscientiousness; and SIP was lower on agreeableness and conscientiousness (average Cohen’s d=|.77|). Differences were observed among the psychotic disorder groups, with effects up to d=1.38. In support of the complication model, the non-recovered group was significantly higher on mistrust, eccentric perceptions, and detachment but lower on extraversion and conscientiousness than the recovered group (average d=|.57| across measures). In support for the scar model, individuals who met threshold for recovery continued to manifest personality deviations, although smaller in magnitude (average d=|.32| across measures) compared to the never-psychotic group. Taken together, this study found support for both the complication and scar models, suggesting that while current symptoms are associated with personality differences, psychosis is associated with permanent alterations in personality.

Keywords: Big five, five factor model, schizophrenia, bipolar disorder, depression, substance-induced psychosis

General Scientific Summary

There are multiple, non-mutually exclusive models to explain the relation between personality and psychopathology. The current study provides evidence for two models, which together suggest that the experience of psychosis is associated with personality differences compared to healthy individuals and that these differences persist to varying degrees following symptom remission.

Multiple, non-mutually exclusive models have been put forth to describe relations between psychopathology and personality, or one’s characteristic thoughts, feelings, and behaviors (Clark, 2005; Klein et al., 2011). However, the relation in individuals with psychotic disorders is unclear. Evidence suggests that mean levels of personality traits in individuals with psychosis differ from unaffected individuals (for a meta-analytic review, see Ohi et al., 2016). Yet, these data come from a small literature which has almost exclusively focused on individuals with a schizophrenia diagnosis with limited information given about current symptomology. Thus, it is not clear what model(s) of psychopathology-personality in psychosis is supported or what the personality profiles are for individuals with different psychotic disorder diagnoses. As tests of models of psychopathology-personality in psychosis, the current study examined the personalities of individuals with one of four psychotic disorders as well as the personalities of a group of never-psychotic individuals.

One model of psychopathology-personality is the complication model. This model states that personality traits fluctuate with levels of psychosis and revert to baseline levels with the remission of symptoms.1 The complication model can be evaluated in two ways. One way is to compare the personality of the same people before and after first onset. Another way is to compare the personality of people who have symptom remission to people who did not (i.e., in a post-onset sample). The scar model purports that psychosis is associated with permanent changes in personality. That is, personality does not revert after symptom amelioration. If the personality of symptomatic individuals is compared to never-psychotic individuals, the complication + scar model is evaluated. That is, the effects of having current symptoms coupled with the effects of psychosis on personality are simultaneously evaluated. In the current study, we used personality data from a sample of individuals who were given a psychotic disorder diagnosis approximately 20 years earlier, some of whom had reached a level of recovery, to test for evidence of the complication + scar, complication, and scar models of psychosis.

The “Big Five,” or five-factor model (FFM) of personality, evolved from descriptions of personality traits found in natural language (Goldberg, 1993; John & Srivastava, 1999; McCrae et al., 2000). With robust support (for a review, see Widiger & Crego, 2019), five broad dimensions emerged—neuroticism, extraversion, agreeableness, conscientiousness, and openness to experience—with maladaptive variants for each pole of these dimensions (e.g., detachment as a maladaptive variant of extraversion) also identified.2 Each of these broad traits and their maladaptive variant fall on the same continuum (Krueger & Eaton, 2010). These dimensions of personality, as well as their maladaptive variants, have been linked to psychopathology (Krueger & Tackett, 2003), including psychosis (Berenbaum & Fujita, 1994; Franquillo et al., 2021; Longenecker et al., 2020; Shi et al., 2018).

The structure of the FFM of personality has been replicated in individuals with a psychotic disorder (Cicero et al., 2019), but overall, limited work has been done to understand the personality profiles of these individuals. For individuals with a first episode of psychosis (e.g., within 1–2 years of their first hospitalization), this small literature suggests that they are higher on neuroticism (Cohen’s d = 0.71 based on weighted average) and openness (Cohen’s d = 0.483), but lower on extraversion (Cohen’s d = −0.98 based on weighted average), agreeableness (Cohen’s d = 0.61 based on weighted average), and conscientiousness (Cohen’s d = −0.97) compared to healthy individuals (Couture et al., 2007; Gurrera et al., 2014). Of note, there is not a clear relation between openness and psychosis (and openness is largely unrelated to psychopathology in general; Kotov et al., 2010; Ohi et al., 2016). That is, the relation between openness and psychosis in individuals with psychotic disorders (or differences between individuals with psychosis and unaffected individuals) is weak, and if anything, is in the opposite direction than expected (for reviews, see Franquillo et al., 2021; Dinzeo & Docherty, 2007). Thus, the current study did not collect data on the openness dimension.

The limited work on personality and psychosis established a strong association between psychotic disorders and four of the five FFM dimensions, but it is unclear how much of these relations are transient (i.e., complication model) versus enduring (i.e., scar model). Similarly, a meta-analysis of personality of people with schizophrenia (patient N = 460; 430 individuals in a chronic stage of illness) found that these individuals are higher on neuroticism (Hedge’s g = 1.10) but lower on extraversion (Hedge’s g = −0.79), agreeableness (Hedge’s g = −0.51), and conscientiousness (Hedge’s g = −0.59) compared to non-affected individuals (Ohi et al., 2016). However, the effects in Ohi et al., 2016 were not reported separately for individuals with or without current psychotic symptoms (i.e., who had reached a level of recovery versus who had not), leaving it unclear whether findings support the complication and/or scar models.

At the same time, the experience of psychosis is not exclusive to a schizophrenia diagnosis, and even fewer studies have assessed personality in individuals with other psychotic disorders, including bipolar disorder with psychotic features (BPp), major depressive disorder with psychotic features (MDDp), or substance-induced psychosis (SIP). Literature amassed from non-psychotic individuals with a mood or substance use disorder suggest both shared and unique personality differences compared to unaffected individuals. Among people with mood or substance use disorders but no history of psychosis, there are very large differences in levels of neuroticism compared to healthy comparison groups (e.g., Cohen’s d = 1.33 for major depressive disorder, Kotov et al., 2010; Hedge’s g = 1.44 for bipolar disorder, Hanke et al., 2022). Thus, relations between mood and substance use disorders with neuroticism are ubiquitous. At the same time, there is evidence of unique relations between mood and substance use disorders with other personality dimensions. Depression has been linked to low extraversion (Cohen’s d = −0.62; Kotov et al., 2010) and low conscientiousness (Cohen’s d = −0.90; Kotov et al., 2010). Also, extraversion and conscientiousness are lower in people with bipolar disorder compared to healthy individuals (Hedge’s g = −0.38 and −0.78, respectively; for a meta-analytic review, see Hanke et al., 2022). In contrast to extraversion and conscientiousness, agreeableness has been found to be largely unrelated to internalizing pathology (Kotov et al., 2010), suggesting a lack of relation with mood disorders. For individuals with a substance use disorder or problematic/risky substance use, meta-analytic findings (Kotov et al., 2010; Malouff et al., 2007; Ruiz et al., 2008) suggest they are lower on conscientiousness and lower on agreeableness than healthy individuals (e.g., Cohen’s d = −1.10 and −0.60, respectively; Kotov et al., 2010). In sum, evidence from individuals who are not psychotic but have a mood or substance use disorder suggest that there are shared and unique differences in personality dimensions compared to unaffected adults. However, the pattern of differences for individuals with mood disorders with psychotic symptoms or substance-induced psychosis is unclear. That is, it is not clear whether that psychosis is not associated with uniform changes in personality. It is also not clear how models of psychopathology-personality apply when these individuals are included in a psychotic disorder sample.

Beyond the dimensions of the five factor model, maladaptive personality dimensions have shown associations with psychosis, namely psychoticism and detachment. Psychoticism is characterized by unusual experiences and beliefs (e.g., general mistrust), eccentricity, and perceptual abnormalities, whereas detachment is defined by anhedonia, social withdrawal, and intimacy avoidance. Perhaps unsurprisingly, individuals with a psychotic disorder diagnosis show elevations on psychoticism and detachment compared to unaffected individuals (Longenecker et al., 2020; Nilsson et al., 2016). In addition, in samples of individuals with a psychiatric disorder, higher psychoticism and lower detachment discriminated people with a psychotic disorder from people with other psychiatric disorders4 (Bastiaens et al., 2019; Meliante et al., 2021). Similar to associations with five factor model dimensions, it is not clear whether there is a similar pattern of differences for individuals with other psychotic disorders for these maladaptive traits. It is also not clear whether findings for these maladaptive traits support the complication and/or scar models alone or whether they apply similarly to a sample that includes individuals with different psychotic disorder diagnoses.

In search of evidence in support of different models of psychopathology-personality in psychosis, we used an epidemiologic sample of individuals with different psychotic disorders (SZ, BPp, MDDp, and SIP) and compared their scores on four of the five factor model traits (neuroticism, extraversion, agreeableness, and conscientiousness) and three dimensions or facets of maladaptive traits (mistrust, eccentric perceptions, and detachment) to individuals with no history of psychosis.

Because psychosis is strongly associated with neuroticism (Ohi et al., 2016), as well as mistrust, eccentric perceptions, and detachment (Morey et al., 2003), we hypothesized that all diagnostic groups would be higher on these traits compared to the never-psychotic group. In addition, we made predictions specific to diagnostic group based on extant research (e.g., Boyette et al., 2013; Hanke et al., 2022; Kotov et al., 2010; Ruiz et al., 2008). We expected that individuals with SZ and SIP would be lower on agreeableness and lower on conscientiousness than never-psychotic individuals. We also expected the SZ group to be lower on extraversion than the never-psychotic group. We predicted that individuals with BPp and MDDp would be lower on extraversion and conscientiousness than never-psychotic individuals.

We also tested whether there were any differences on personality traits between the psychotic disorder groups and made specific predictions based on differences in effect sizes from meta-analytic research. We hypothesized that the SZ group and BPp group would be lower on neuroticism than the MDDp group. We predicted that the BPp group would be higher on extraversion than the SZ and MDDp groups. We also hypothesized that the SIP group would be lower on conscientiousness than the SZ and BPp groups. We anticipated that the SZ and SIP groups would be lower on agreeableness than the MDDp and BPp groups. If these hypotheses were supported, this would provide evidence for the complication + scar model of psychopathology-personality in psychosis as well as provide evidence that psychosis is not associated with uniform changes in personality.

In order to isolate effects of complication (and control for scar effects), we compared the personalities of individuals with psychosis who had not reached recovery (i.e., non-recovered group) to individuals with psychosis who had reached recovery (i.e., recovered group). If significant differences in personality were found between the groups, this would provide evidence of the complication model in psychosis. In order to isolate effects of scar (and control for complication effects), we compared the personalities of individuals with psychosis who had reached recovery (i.e., recovered group) to the personalities of the never-psychotic group. If significant differences in personality remained for the recovered group, this would provide evidence of the scar model in psychosis.

Methods

Participants

Data were drawn from the Suffolk County Mental Health Project, a longitudinal study of first-admission psychosis (Bromet et al., 1992, 2011; Fett et al., 2020). Over a 6-year period, individuals were recruited from the 12 inpatient facilities in Suffolk County, New York. Eligibility criteria included residence in Suffolk County, age between 15 and 60, ability to speak English, IQ > 70, first admission within the past 6 months, current psychosis, and no apparent medical etiology for psychotic symptoms. For additional details about this sample, including recruitment, see Bromet and colleagues (1992).

In total, 628 participants met inclusion criteria. Diagnoses were made by a consensus of study psychiatrists at the 6-month follow-up using all available information accumulated: Structured Clinical Interview for DSM-4 diagnostic interviews with participants, interviews with participants’ significant others, medical records, and behavioral ratings by masters-level interviewers, as described in Bromet et al. (1992).

Follow-up interviews were conducted at multiple timepoints, including 20 years after baseline admission. As of the 20-year follow-up, 81 participants had died. Of the 547 surviving participants, 70 were lost to follow-up, 33 could not be reached for varying reasons (moved to another country, institutionalized, or too ill to consent), and 71 declined to be interviewed. The remaining 373 participated in the 20-year follow-up in some form. Of these 373 individuals, 31 had a diagnosis other than SZ, BPp, MDDp, or SIP and were excluded, and 103 participated in the follow-up but did not complete personality measures either due to time limitation, because they were interviewed remotely and didn’t return mailed forms, or because their primary form of participation was via interviews with an informant. Thus, the current study’s sample size of 239 was determined by the availability of personality data and the presence of either a diagnosis of SZ, BPp5, MDDp, or SIP.

Individuals with personality data at the 20-year follow-up were younger compared to individuals who did not participate in the 20-year follow-up, t(626) = 3.03, p = .003, d = .25. This age difference is likely due to the fact that older participants were more likely to be deceased and thus, not be able to participate in the 20-year follow-up. There were no other statistically significant differences in demographics (gender, race/ethnicity) or clinical (SANS and SAPS ratings) between these groups.

Data were also collected from never-psychotic individuals (n = 257). The never-psychotic group was recruited using random digit dialing from zip codes where the clinical group currently resided and was matched on age and gender. Exclusion criteria were lifetime psychosis (assessed by the Structured Clinical Interview for DSM-4) or lifetime psychiatric hospitalization. Although never psychotic, some individuals in the never-psychotic group did have a lifetime history of other forms of psychopathology including anxiety (14.5%), depressive (25.1%), and substance use (18.8%) disorders. For more details on this group, see (Velthorst et al., 2017). See Table 1 for demographic information.

Table 1.

Demographics and descriptive statistics for personality measures by group

Schizophrenia (N = 94) BP with psychotic features (N = 78) MDD with psychotic features (N = 50) Substance- induced psychosis (N = 17) Never-psychotic (N = 257) Recovered psychotic group (N = 97) Non-recovered psychotic group (N = 102)
Mean (SD) or %
Demographics
 Women 39.4% 52.6% 50.0% 17.6% 44.4% 47.4% 43.1%
 Age at follow-up (years) 46.67 (7.73) 48.13 (9.63) 51.67 (10.46) 45.71 (8.64) 50.43 (9.02) 46.24 (9.32) 49.05 (8.62)
 Asian 3.2% 0% 0% 0% 0.8% 0% 2.9%
 African American or Black 18.1% 3.8% 6.0% 11.8% 6.2% 8.2% 12.7%
 White 69.1% 88.5% 86.0% 76.5% 87.2% 85.6% 74.5%
 More than one race 5.3% 0% 4.0% 0% 2.3% 2.1% 4.9%
 Other or Unknown 4.3% 7.7% 4.0% 11.8% 3.5% 4.1% 4.9%
Personality measures
 Neuroticism 21.74 (6.12) 20.99 (7.52) 25.84 (6.89) 24.41 (6.97) 18.22 (6.58) 21.71 (7.01) 23.19 (7.27)
 Extraversion 24.02 (5.55) 26.60 (6.48) 23.64 (7.41) 22.24 (6.30) 27.78 (6.28) 26.49 (6.42) 23.58 (6.29)
 Agreeableness 35.71 (5.66) 38.71 (4.57) 35.53 (6.08) 33.59 (6.30) 38.66 (5.08) 37.20 (5.67) 35.63 (5.71)
 Conscientiousness 33.16 (6.54) 35.92 (6.45) 32.04 (6.53) 30.47 (6.39) 37.56 (5.56) 35.17 (6.32) 32.51 (6.59)
 Mistrust 7.36 (4.62) 3.79 (4.27) 7.26 (5.06) 10.20 (6.07) 2.71 (3.41) 4.19 (4.31) 8.46 (5.08)
 Eccentric Perceptions 3.56 (3.42) 1.87 (2.40) 3.16 (4.03) 5.26 (4.24) 1.36 (1.69) 1.84 (2.70) 4.04 (3.74)
 Detachment 7.12 (3.82) 4.83 (3.90) 7.41 (5.01) 9.20 (3.77) 3.85 (3.61) 4.62 (3.78) 8.51 (3.89)
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Note: MDD = Major Depressive Disorder, BP = Bipolar Disorder

Measures

Measures were collected from all participants at the same wave.

Modified Big Five Inventory (BFI; John & Srivastava, 1999).

The BFI is a self-report measure of personality. In the current study, data were only collected for four of the five traits (Neuroticism, Extraversion, Agreeableness, Conscientiousness). We did not collect data on Openness. Participants are asked to indicate the extent to which each of the 34 items (all Cronbach’s αs > .76) apply to them on a scale of 1 (Disagree strongly) to 5 (Agree strongly). Mean ratings for each dimension were calculated.

Modified Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993).

The SNAP is a self-report, true-false measure of trait dimensions relevant to personality pathology, including psychoticism. The full measure contains 375 items and 15 primary scales. In the current study, only three scales that are most relevant to the psychosis spectrum—mistrust, eccentric perceptions6, and detachment (all Cronbach’s αs > .83)—were administered to minimize participant burden. See Table 1 for descriptive statistics on personality measures.

Statistical analysis

To test our predictions related to group differences in personality, a series of independent samples t-tests were conducted (each psychotic disorder group versus never-psychotic group; every psychotic disorder group versus each of the other three). To isolate effects of complication and scar, we stratified the sample based on recovery status. Recovery status was defined according to the criteria of Liberman and colleagues (2002) which included ratings of 4 or less on multiple items from the Brief Psychiatric Rating Scale (Overall & Gorham, 1962) as well as ratings of 2 or more on items assessing occupational and social functioning from the Quality of Life Scale (Heinrichs et al., 1984). Because of the limited number of individuals who met criteria for recovery (SZ n = 21; BPp n = 46; MDDp n = 24; SIP n = 6), we combined individuals who met criteria for recovery from all diagnostic groups into one recovered group and compared their personalities to the personalities of a combined, non-recovered group (to test complication effects) and to the never-psychotic group (to test scar effects). Finally, to test whether level of current symptoms impacted any group differences found, we compared the personalities of individuals with psychosis to the never-psychotic individuals controlling for current reality distortion symptoms. To do this, we first ran a linear regression with reality distortion symptoms predicting personality variables and saved the residuals. Then, we ran t-tests for each set of group comparisons using these residuals.

For all tests, alpha levels were set to .05 and Cohen’s ds (Cohen, 1988) were calculated as an indication of the size of the effect for group differences, with a small effect equally d = 0.2, a medium effect equally d = 0.5, a large effect equally d = 0.8, and a very large effect equally d = 1.2.

Transparency and Openness

We report how we determined our sample size, all data exclusions, all manipulations, and all measures in the study. This work was not pre-registered. The data and results output files are available on the Open Science Framework at https://osf.io/2845b/.

Results

A Test of the Complication + Scar model: Comparisons of each psychotic disorder group with the never-psychotic group

We compared the personalities of each psychotic disorder group with the never-psychotic group. Table 2 shows test statistics for group comparisons for each personality measure. Unless otherwise stated, all results reported below were statistically significant at p < .05. Consistent with our hypotheses, individuals with any psychotic disorder diagnosis were higher on neuroticism than the never-psychotic group, with differences in Cohen’s ds ranging from .41 to 1.15 (average d = .76). Our hypotheses that all diagnostic groups would have higher levels of mistrust, eccentric perceptions, and detachment compared to the never-psychotic group were supported for all group comparisons except one—for the BPp group, there were small, trending group differences in the expected direction for mistrust and eccentric perceptions (average d = .28).

Table 2.

Psychotic vs. Never-psychotic group comparisons for each personality measure

Schizophrenia BP with psychotic features MDD with psychotic features Substance-induced psychosis Recovered psychotic disorders Non-recovered psychotic disorders
t(df) p d t(df) p d t(df) p d t(df) p d t(df) p d t(df) p d
N 4.47 (339) <.001 .55 (.30, .79) 3.10 (323) .002 .41 (.15, .67) 7.35 (296) <.001 1.15 (.83, 1.47) 3.74 (264) <.001 .94 (.44, 1.43) 4.28 (341) <.001 .52 (.28, .76) 6.16 (346) <.001 .73 (.49, .97)
E −4.95 (338) <.001 −.62 (−.86, −.37) −1.42 (326) .157 −.19 (−.44, .07) −4.03 (298) <.001 −.64 (−.96, −.32) −3.52 (268) .001 −.88 (−1.38, −.39) −1.65 (344) .100 −.20 (−.44, .04) −5.53 (346) <.001 −.66 (−.90, −.42)
A −4.58 (342) <.001 −.56 (−.81, −.32) 0.09 (329) .930 .01 (−.24, .27) −3.38 (61.6) .001 −.59 (−.90, −.28) −3.92 (269) <.001 −.98 (−1.48, −.48) −2.32 (348) .021 −.28 (−.51, −.04) −4.82 (349) <.001 −.57 (−.81, −.34)
C −6.06 (335) <.001 −.75 (−1.00, −.50) −2.13 (320) .034 −.28 (−.55, −.02) −6.06 (295) <.001 −.96 (−1.28, −.64) −5.04 (265) <.001 −1.26 (−1.76, −.76) −3.40 (341) .001 −.41 (−.65, −.17) −7.12 (342) <.001 −.86 (−1.11, −.62)
MS 8.56 (119.3) <.001 1.24 (.97, 1.50) 1.98 (101.1) .050 .30 (.04, .56) 6.04 (57.1) <.001 1.22 (.90, 1.54) 4.88 (15.6) <.001 2.07 (1.53, 2.61) 2.99 (144.5) .003 .40 (.16, .64) 9.97 (121.8) <.001 1.46 (1.19, 1.72)
EP 5.81 (102.4) <.001 .97 (.72, 1.22) 1.74 (100.5) .084 .27 (.02, .53) 3.01 (49.1) .004 .81 (.49, 1.13) 3.78 (16.4) .002 2.01 (1.49, 2.53) 1.62 (124.9) .108 .24 (.00, .47) 6.69 (107.8) <.001 1.10 (.85, 1.35)
DET 7.18 (331) <.001 .89 (.64, 1.14) 2.02 (318) .044 .27 (.01, .53) 4.72 (58.3) <.001 .92 (.60, 1.23) 5.90 (260) <.001 1.48 (.97, 1.99) 1.72 (338) .086 .21 (−.03, .44) 10.41 (337) <.001 1.26 (1.00, 1.51)
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Note: N = Neuroticism, E = Extraversion, A = Agreeableness, C = Conscientiousness, MS = Mistrust, EP = Eccentric Perceptions, DET = Detachment; BP = Bipolar Disorder, MDD = Major Depressive Disorder; p = p-value; d = Cohen’s d (95% confidence intervals)

As hypothesized, individuals with SZ were lower on extraversion (d = −.62), lower on agreeableness (d = −.56), and lower on conscientiousness (d = −.75) than the never-psychotic group. These group differences were medium in size. Also as hypothesized, individuals with MDDp were lower on extraversion (d = −.64) and conscientiousness (d = −.96) than the never-psychotic group. These differences were medium-to-large in magnitude. The MDDp group also had a medium-sized, lower level of agreeableness than the never-psychotic group (d = −.59).

As predicted, individuals with SIP were lower on agreeableness (d = −.98) and conscientiousness (d = −1.26) than the never-psychotic group. These differences were large in magnitude. The SIP group also had a large-sized, lower level of extraversion than the never-psychotic group on extraversion (d = −.88). Although in the expected direction (BPp < NP), the difference between individuals with BPp and the never-psychotic group on extraversion was not statistically significant (d = −.19).

Is personality uniform among psychotic disorders? Comparisons among psychotic disorder groups

Figure 1 plots the z-scores for the psychotic disorder groups on each personality measure (standardized in comparison to the never-psychotic group), and Table 3 shows psychotic disorder group comparisons for each personality measure.

Figure 1.

Figure 1.

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Z-score comparisons for each personality measure across psychotic disorder groups

N = Neuroticism, E = Extraversion, A = Agreeableness, C = Conscientiousness, MS = Mistrust, EP = Eccentric Perceptions, DET = Detachment

Table 3.

Psychotic disorders group comparisons for each personality measure

Schizophrenia vs. BP with psychotic features Schizophrenia vs. MDD with psychotic features Schizophrenia vs. Substance-induced psychosis BP with psychotic features vs. MDD with psychotic features BP with psychotic features vs. Substance-induced psychosis MDD vs. Substance-induced psychosis Recovered vs. Non-recovered psychotic disorders
t(df) p d t(df) p d t(df) p d t(df) p d t(df) p d t(df) p d t(df) p d
N 0.72 (166) .476 .11 (−.19, .41) −3.62 (139) <.001 −.64 (−.99, −.28) −1.62 (107) .109 −.43 (−.95, .09) −3.64 (123) <.001 −.67 (−1.03, −.30) −1.72 (91) .089 −.46 (−.99, .07) 0.73 (64) .467 .21 (−.35, .76) −1.45 (193) .15 −.21 (−.49, .07)
E −2.73 (160) .007 −.43 (−.74, −.12) 0.31 (74.5) .756 .06 (−.29, .41) 1.19 (102) .238 .32 (−.21, .84) 2.32 (120) .022 .43 (.06, .80) 2.52 (90) .014 .68 (.14, 1.21) 0.69 (62) .490 .20 (−.36, .75) 3.15 (188) .002 .46 (.17, .75)
A −3.73 (165) <.001 −.58 (−.89, −.27) 0.17 (137) .861 .03 (−.32, .38) 1.39 (105) .167 .37 (−.15, .89) 3.14 (82) .002 .61 (.24, .98) 3.89 (92) <.001 1.04 (.49, 1.59) 1.12 (64) .265 .32 (−.24, .87) 1.92 (193) .06 .27 (−.01, .56)
C −2.66 (157) .009 −.42 (−.74, −.11) 0.94 (132) .346 .17 (−.18, .53) 1.56 (102) .123 .41 (−.11, .93) 3.19 (117) .002 .60 (.22, .97) 3.14 (87) .002 .85 (.30, 1.39) 0.86 (62) .396 .24 (−.32, .80) 2.82 (185) .005 .41 (.12, .70)
MS 5.04 (157) <.001 .80 (.48, 1.13) 0.12 (133) .907 .02 (−.33, .37) −2.14 (100) .035 −.58 (−1.12, −.04) −4.09 (120) <.001 −.76 (−1.13, −.38) −4.01 (18.4) .001 −1.38 (−1.96, −.80) −1.91 (63) .060 −.55 (−1.12, .02) −6.18 (176.8) <.001 −.91 (−1.21, −.61)
EP 3.72 (155.9) <.001 .57 (.25, .88) 0.62 (133) .539 .11 (−.24, .47) −1.80 (103) .075 −.48 (−1.00, .05) −1.99 (66.1) .051 −.41 (−.78, −.05) −3.19 (18.3) .005 −1.21 (−1.76, −.65) −1.82 (62) .074 −.51 (−1.07, .05) −4.64 (169.2) <.001 −.67 (−.97, −.38)
DET 3.77 (161) <.001 .59 (.28, .91) −0.34 (79.6) .731 −.07 (−.42, .28) −2.06 (103) .042 −.55 (−1.07, −.02) −3.04 (84.8) .003 −.59 (−.96, −.22) −4.20 (90) <.001 −1.13 (−1.68, −.57) −1.35 (64) .182 −.38 (−.92, .18) −7.01 (189) <.001 −1.01 (−1.31, −.71)
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Note: N = Neuroticism, E = Extraversion, A = Agreeableness, C = Conscientiousness, MS = Mistrust, EP = Eccentric Perceptions, DET = Detachment; BP = Bipolar Disorder, MDD = Major Depressive Disorder; p = p-value; d = Cohen’s d (95% confidence intervals)

Compared to the never-psychotic group, the SZ group had large elevations on mistrust, eccentric perceptions, and detachment, coupled with a moderate elevation on neuroticism and moderate reductions in extraversion, agreeableness, and conscientiousness. Compared to the SZ group, the BPp group was lower on mistrust, eccentric perceptions, and detachment (all ds ≥ |.57|), but higher on extraversion, agreeableness, conscientiousness (both ds ≥ |.42|). The SIP group was higher on mistrust and detachment compared to the SZ group (both ds ≥ |.55|). As hypothesized, MDDp was higher on neuroticism than the SZ group (d = .64).

In addition to these contrasts with SZ, the BPp group was higher than the MDDp and SIP groups on extraversion, agreeableness, and conscientiousness (all ds ≥ .43), but lower than both groups on mistrust and detachment (all ds ≥ |.59|). The BPp group was lower on neuroticism than the MDDp group (d = −.67) as hypothesized, and was also lower than the SIP group on eccentric perceptions (d = −1.21). Although in the predicted direction (MDDp > SIP), there was a small, non-statistically significant difference between the MDDp and SIP groups on agreeableness (d = |.32|).

A Test of the Complication Model: Comparison of the non-recovered psychotic disorder group and recovered psychotic disorder group

We compared the personalities of individuals who did not (n = 102) and who did (n = 97)7 meet criteria for recovery from all diagnostic groups. As can be seen in Table 3 and Figure 28, the non-recovered group was higher on mistrust, eccentric perceptions, and detachment (all ds ≥ |.67|), and lower on extraversion and conscientiousness (both ds ≥ |.41|) as compared to the recovered group. These effects ranged from small-to-large in size. There were also small, non-significant differences between the groups for neuroticism and agreeableness (|.21| ≤ ds ≤ |.27|).

Figure 2.

Figure 2.

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Z-comparisons of personality traits between non-recovered and recovered psychotic disorder groups

N = Neuroticism, E = Extraversion, A = Agreeableness, C = Conscientiousness, MS = Mistrust, EP = Eccentric Perceptions, DET = Detachment

A Test of the Scar Model: Comparison of the recovered psychotic disorder group and the never-psychotic disorder group

Last, we compared the personalities of the recovered group to the never-psychotic group (see Table 2). The recovered group showed the same pattern of personality differences as the non-recovered group compared to the never-psychotic group. However, the sizes of these effects were small-to-medium (versus medium-to-very large for unrecovered-NP comparisons), with some differences being statistically significant (neuroticism, agreeableness, conscientiousness, and mistrust) and others not (extraversion, eccentric perceptions, or detachment) (versus all statistically significant for unrecovered-NP comparisons).9

Finally, to test whether level of current symptoms impacted the group differences found, we compared the personalities of individuals with psychosis to the never-psychotic individuals controlling for current reality distortion symptoms. We found an identical pattern of group differences for each psychotic disorder group (SZ, BPp, MDDp, SIP, recovered, non-recovered) compared to the never-psychotic group. See Supplementary Tables 2 and 3 for full results.

Discussion

As tests of models of psychopathology-personality in psychosis, the current study examined the personalities of individuals with one of four psychotic disorders as well as the personalities of a group of never-psychotic individuals. In general, we found medium-to-large differences in the personalities of those with a psychotic disorder compared to those without a psychotic disorder and found unique profiles across the psychotic disorder groups. We found evidence of complication effects, in that the non-recovered group showed small to large differences compared to the recovered group. Albeit to a lesser degree, we also found that the personality profiles of individuals in the recovered group remain different compared to the never-psychotic disorder group, providing evidence of scar effects. In sum, the current study found support for both independent complication and scar effects as well as effects for the models when tested together.

What are the personality profiles of these disorders decades after onset? Support for the complication + scar model

The vast majority of previous work examining the personality of individuals with a psychotic disorder has focused on schizophrenia. We found that compared to the never-psychotic group, individuals with schizophrenia were higher on neuroticism, lower on extraversion, lower on conscientiousness, and lower on agreeableness. Group differences were medium in size (average Cohen’s d = .62), consistent with meta-analytic findings of Ohi and colleagues (2016; average Hedge’s g of these four traits = .75). In the current study, differences were even larger between the SZ and never-psychotic group for maladaptive personality dimensions (average Cohen’s d = 1.03). Taken together, these findings provide support for the complication + scar model of personality for psychosis.

Are personality differences uniform among all people with psychotic disorders?

Because of the lack of previous literature, it was unclear whether personality differences are uniform among all people with a psychotic disorder diagnosis or if they differ among people with psychotic disorder diagnoses compared to a never-psychotic group. As hypothesized, the current works showed that there are both shared (e.g., higher neuroticism and detachment than the never-psychotic group) and unique differences among the psychotic disorder groups compared to the never-psychotic group. Overall, compared to the never-psychotic group, there was an average of small differences for the BPp group, large differences for the MDDp (and SZ) group, and very large differences for the SIP group. These findings indicate that when different psychopathological symptoms occur with psychosis, associations with personality vary. This is consistent with work suggesting that comorbidities with psychosis are related to differential functional and clinical outcomes (Castle et al., 2021).

Based on meta-analytic findings from studies of personality and bipolar disorder (Hanke et al., 2022), we predicted that individuals with BPp would be lower on extraversion and conscientiousness than the never-psychotic group. Our hypothesis regarding conscientiousness was supported. However, although the BPp group was less extraverted, the effect was small in magnitude and non-statistically significant. Personality associations may vary with individuals’ current mood state (manic versus euthymic versus depressed; Barnett et al., 2011). The current sample had a very small percentage of people in a current mood episode (5%), which prevented examination of mood effects. However, the current findings suggest the relation between extraversion and bipolar disorder are small when individuals’ moods are generally euthymic. Future research could test whether similar relations with personality are found as mood states vary in individuals with BPp.

Because agreeableness has been found to be largely unrelated to internalizing pathology (Kotov et al., 2010), we did not predict differences between MDDp (or BPp) with the unaffected group. However, we found a statistically significant, moderately-sized effect between the MDDp and never-psychotic groups (but not between the BPp and never-psychotic groups). Thus, it is possible that the coupling of mood and psychotic symptoms is associated with lower agreeableness compared to having a mood disorder alone. Future research should attempt to replicate this non-hypothesized finding to test for its robustness.

As predicted, we found large-to-very large statistically significant differences between the SIP group and the never-psychotic group for neuroticism and agreeableness, as well as between the SIP and BPp groups for conscientiousness. Although not predicted, we also found several other medium-to-very large differences between the SIP and other groups for other personality dimensions.

Investigations of SIP are particularly challenging. Due to difficulties in reporting, among other reasons, it is often difficult to distinguish between SIP and comorbid substance use disorder-psychotic disorder. Further, individuals with SIP in which symptoms remit following metabolization of the drug are frequently lost to follow-up (Fiorentini et al., 2021), making it difficult to study this population.

Of the work that has been done in this challenging area, some suggest that individuals with SIP exhibit fewer positive and fewer negative symptoms than individuals with primary psychotic disorders, but that they have more depressive and anxiety symptoms (Fiorentini et al., 2021; Garson et al., 2023). At the same time, extant work suggests that the co-occurrence of a substance use disorder and schizophrenia is associated with worse outcomes, including increased morbidity and mortality, more severe symptoms, increased rates of relapse, and less stable trajectories (Garson et al., 2023). Taken together, there are likely several contributing factors to any differences between personality profiles of individuals with both a history of substance use and psychosis. Although the current study found medium-to-very large-sized group differences in personality dimensions, replication of findings for the SIP group is warranted because of the small size of this group and overall difficulty in SIP investigations.

Last, because of the lack of previous literature, it was also unclear how the personalities of different psychotic disorder groups compared to each other. Of all group comparisons, the SZ and MDDp groups were most similar to each other (average Cohen’s d = .16), whereas the BPp group showed the most differences compared to the other groups in levels of four of the five factor model traits and maladaptive traits. Specifically, the BPp group showed the highest levels of agreeableness and conscientiousness, as well as lowest levels of mistrust and detachment of all the psychotic disorder groups. This suggests that, on average, the personalities of individuals with BPp are most similar to never-psychotic individuals. Overall, findings for the BPp, MDDp, and SIP groups provide support for the complication + scar model for personality in psychosis and suggest that these effects apply to a sample that includes individuals with different psychotic disorder diagnoses.

How do personality profiles compare between non-recovered and recovered individuals? Support for the complication model

When comparing individuals with a psychotic disorder who had not reach recovery to those who had reached recovery, we found small-to-large size differences (average Cohen’s d = |.57| for all traits; average Cohen’s d = |.34| for four of the five factor model traits), with the largest of these differences being for maladaptive traits (all medium-to-large sized; average Cohen’s d = |.87|). This suggests that after controlling for scar effects, complication effects (i.e., effects of current symptoms) are associated with differences in personality among individuals with psychotic disorders.

When we compare the effects of the recovered group in the current study to individuals in their first episode, additional support for complication effects is provided. The recovered group showed the same pattern of results as seen in a review of the first-episode psychosis literature (higher on neuroticism, lower on extraversion, lower on agreeableness, and lower on conscientiousness). However, recovered individuals show small-to-medium effects (average Cohen’s d = |.35|) whereas individuals in their first episode show medium-to-large effects compared to never-psychotic individuals (weighted average of Cohen’s d > |.82|; Couture et al., 2007; Gurrera et al., 2014), Thus, we again find support for the complication model in psychosis when scar effects are controlled.

How do personality profiles compare between recovered and never-psychotic individuals? Support for the scar model

We found that compared to the never-psychotic group, the non-recovered group was statistically significantly higher on neuroticism, mistrust, eccentric perceptions, and detachment, and statistically significantly lower on extraversion, agreeableness, and conscientiousness (ds ranged from medium-to-very large in size). This pattern of personality differences is identical to the pattern seen when comparing the recovered group to the never-psychotic group. However, the sizes of these effects for the recovered group were small-to-medium compared to the medium-to-very large effects for the non-recovered group. This suggests that after controlling for complication effects, scar effects (i.e., effects of psychosis on personality) are associated with lasting personality differences.

Implications for dimensional classification

The current study focused on traditional categorical diagnoses because personality abnormalities are recognized to be at the core of internalizing and externalizing psychopathology, but the relation was less clear for psychosis. Given the numerous problems with categorical diagnoses, there is a movement towards dimensional classification of psychopathology (Kotov et al., 2017). One model that has garnered significant support is the Hierarchical Taxonomy of Psychopathology (HiTOP), a dimensional nosology that organizes symptoms and traits hierarchically based on observed covariation. A growing body of work has highlighted the benefits of HiTOP, including its ability to predict long-term outcomes above and beyond categorical diagnoses (Martin, Jonas, Lian, Foti, Donaldson, Bromet, & Kotov, 2021). The results of the current study extend previous work by providing evidence for how different disorders are positioned in the space defined by HiTOP. For example, schizophrenia as a group is high on Detachment and Psychoticism spectra, and slightly elevated on the Internalizing and Externalizing spectra. MDDp has a profile similar to schizophrenia but is also elevated on the Internalizing spectrum. In contrast, BPp shows few elevations on any spectra. Of note, the lack of association between BPp and HiTOP spectra in the current study is likely because we focused on the trait aspects of spectra. During episode of mania, an individual is elevated on some dimensions but evidently these elevations are transient and traits are not altered.

Limitations

In the current study, tests of the complication and scar models included vulnerability factors as well. Thus, data from the current study cannot speak to the complication and/or scar models without vulnerability factors. In order to test the vulnerability model, seemingly healthy individuals can be tracked over time, and the personality of those who go on to develop a psychotic disorder can be compared to those who do not. Such work has found that higher neuroticism predicts conversion to schizophrenia or other psychoses (odds ratio = 1.16, 95% CI 1.09 – 1.23; Krabbendam et al., 2002; odds ratio = 1.93, 95% CI 1.09 – 3.43; Van Os & B. Jones, 2001), while higher extraversion might be protective (odds ratio = 0.44, 95% CI 0.23 – 0.84; Van Os & Jones, 2001). There are scant reports on relations with other five factor model traits or maladaptive traits, and future research is needed to address this gap in the literature.

The current study did not include a measure of the openness dimension. Despite evidence that openness’ relations in psychosis are tenuous (for reviews, see Franquillo et al., 2021; Dinzeo & Docherty, 2007) and that openness does not clearly map onto a maladaptive personality trait as the other four FFM dimensions do (e.g., Widiger et al., 2019), its exclusion from the current study may have been a missed opportunity. The strengths of the current study’s sample and methods could have help to clarify relations of openness in psychotic disorders. Based on previous studies that have reported null findings for openness between individuals with a psychotic disorder and unaffected individuals (Franquillo et al., 2021; Dinzeo & Docherty, 2007), it is possible that we would have found openness could be the lone FFM dimension that is not affected by complication and/or scar effects. Future research should include openness to test whether the same pattern of results is found for that dimension as those included in the current sample.

Conclusions

The current study was the first to test for evidence of the complication and scar models of psychosis. Overall, support for both the complication and scar models, together and in isolation, were found, suggesting that while current symptoms are associated with personality differences compared to never-psychotic individuals, psychosis is associated with permanent alterations in personality. The study is also the first to provide support for these models in individuals with different psychotic disorder diagnoses, while also showing there are unique personality profiles among the groups.

Supplementary Material

supplementary materials
open practices disclosure

Footnotes

Data and supplementary materials are available on the Open Science Framework (https://osf.io/2845b/). We have no known conflicts of interest to disclosure.

This study was approved by the Institutional review Board at Stony Brook University (#102354, “Epidemiology of Newly Diagnosed Psychotic Disorders”). The data and results output files are available on the Open Science Framework at https://osf.io/2845b/. This work was not pre-registered. Results from the primary analyses of the current study have not been previously disseminated.

1

The vulnerability model postulates that personality predicts onset of psychopathology. Although perhaps theoretically possible, it is not possible in practice to test other psychopathology-personality models (e.g., complication, scar) in the absence of the vulnerability model because vulnerability factors cannot be controlled. Thus, by default, tests of other models in the current manuscript will include vulnerability factors but for the sake of readability, “vulnerability” will be not be included when referring to these models or their tests (e.g., vulnerability + scar model will be referred to as scar model).

2

The relation of openness with the maladaptive trait of psychoticism is less clear than the relations of the other four broad traits with a maladaptive variant. One particularly compelling explanation for the mixed findings is that relations with psychoticism depend on what subordinate facet of openness is considered and where on these facets one falls (DeYoung et al., 2012).

3

Calculation of effect sizes from the test statistics provided by Couture et al. (2007) show that they also found small-sized group differences for conscientiousness (Cohen’s d = .25) and openness (Cohen’s d = .48). However, because the authors did not report any means/standard deviations and the tests for conscientiousness and openness were not statistically significant (hence, the authors gave no further discussion of the results), the direction of these differences is unknown. Thus, only data from Gurrera et al. (2014) are reported here.

4

Bastiaens et al., found that higher psychoticism and lower detachment, coupled with lower negative affect and lower disinhibition, best discriminated those with a psychotic disorder from people with other psychiatric disorders.

5

For individuals with a BPp, approximately 5% were in a current mood episode.

6

One item from the original eccentric perceptions dimension was dropped for the current analysis because it was largely unrelated to the rest of the scale (near zero corrected item-total correlation) in the present sample.

7

Recovery data were not available for 40 individuals with a psychotic disorder diagnosis a one individual in the NP group. Thus, these individuals could not be included in analyses considering recovery status.

8

See Supplementary Figure 1 for a plot of means for each personality measure for the recovered, non-recovered, and never-psychotic group

9

As another test of differences between the recovered and non-recovered group, we conducted a 2 (Status: Recovered vs. Non-recovered) X 4 (Diagnostic group: schizophrenia, bipolar disorder with psychotic features, major depressive disorder with psychotic features, substance induced psychosis) ANOVA for each of the seven personality outcomes. Overall, there was a relatively consistent pattern of main effects for recovery (for all personality variables) and main effects for diagnosis (N, A, C, MST, EP, DET). There was one statistically significant interaction of Status by Diagnostic group for eccentric perceptions. See Supplementary Table 1 for full results.

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