Relations of internalized stigma with temperament and character in patients with schizophrenia

The cognitive model of negative symptoms: a systematic review and meta-analysis of the dysfunctional belief systems associated with negative symptoms in schizophrenia spectrum disorders

BACKGROUND

The hypothesized cognitive model of negative symptoms, proposed nearly twenty years ago, is the most prevalent psychological framework for conceptualizing negative symptoms in schizophrenia spectrum disorders (SSDs). The aim of this study was to comprehensively validate the model for the first time, specifically by quantifying the relationships between negative symptom severity and all related dysfunctional beliefs.

METHODS

A systematic search was conducted using MEDLINE and PsychINFO, supplemented by manual reviews of reference lists and Google Scholar. Eligible studies were peer-reviewed with data on the direct cross-sectional association between negative symptoms and at least one relevant dysfunctional belief in SSD patients. Screening and data extraction were completed by independent reviewers. Random-effects meta-analyses were performed to pool effect size estimates of z-transformed Pearson's r correlations. Moderators of these relationships, as well as subset analyses for negative symptom domains and measurement instruments, were also assessed.

RESULTS

Significant effects emerged for the relationships between negative symptoms and defeatist performance beliefs (k = 38, n = 2808), r = 0.23 (95% CI, 0.18-0.27), asocial beliefs (k = 8, n = 578), r = 0.21 (95% CI, 0.12-0.28), low expectancies for success (k = 55, n = 5664), r = -0.21 (95% CI, -0.15 - -0.26), low expectancies for pleasure (k = 5, n = 249), r = -0.19 (95% CI, -0.06 - -0.31), and internalized stigma (k = 81, n = 9766), r = 0.17 (95% CI, 0.12-0.22), but not perception of limited resources (k = 10, n = 463), r = 0.08 (95% CI, -0.13 - 0.27).

CONCLUSIONS

This meta-analysis provides support for the cognitive model of negative symptoms. The identification of specific dysfunctional beliefs associated with negative symptoms is essential for the development of precision-based cognitive-behavioral interventions.

Self-Transcendence as a Risk and Resilience Factor in Individuals at Clinical High Risk for Psychosis

AIM

Self-transcendence is a personality feature and psychological resource that involves feelings of connectedness with the universe, all of humanity, and the individual self. Self-transcendence has been positively associated with both positive psychotic symptoms and clinical high risk for developing psychosis status, but studies reporting these findings focus solely on the connectedness-with-universe aspect of self-transcendence. The broader self-transcendence literature, which also includes connection with humanity and oneself, robustly supports self-transcendence as an indicator of well-being. Given this discrepancy, we sought to understand whether self-transcendence should be considered a risk or resilience factor for youth at clinical high risk.

METHODS

We operationalised self-transcendence using two more holistic measures novel to the clinical high risk population. Clinical high risk participants (n = 42) and healthy controls (n = 44) completed the Adult Self-Transcendence Inventory and participated in narrative life story interviews which were coded for self-transcendence themes.

RESULTS AND DISCUSSION

Clinical high risk individuals scored lower than healthy controls on measures of self-transcendence, functioning, and life satisfaction. However, there were no group differences in the relationships between self-transcendence and measures of well-being.

CONCLUSION

Our findings suggest self-transcendence is a part of healthy personality development that may be impacted in clinical high risk individuals yet may still function as a psychological resource for this population, pointing toward new avenues for intervention in clinical high risk and other mental health populations.

Systematic review and meta-analysis of internalised stigma and stigma resistance in patients with psychosis: The impact of individualism-collectivism culture and other individual factors

PURPOSE

This study aimed to meta-analysis the level of internalised stigma experienced by individuals with psychosis worldwide, and the impact of cultural differences, economic status of the studied regions and duration of illness on their levels of internalised stigma. Clinical and individual level factors associated with internalised stigma and stigma resistance were also systematically reviewed.

METHODS

A systematic search of keywords on two scholarly databases were conducted. The individualism index of the countries or regions where the studies were conducted was retrieved from Hofstede's updated measurement of individualism. Economic status of regions was categorised based on their per capita gross national income. Meta-analysis and meta-regression were conducted using the 'metafor' package in R. Factors associated with internalised stigma and stigma resistance were also systematically consolidated.

RESULTS

Seventy-three articles were included in the meta-analysis and the pooled score of both internalised stigma and stigma resistance of individuals with psychosis were within the mild range (2.20 and 2.44, respectively). The meta-regression analysis found high collectivism culture is significantly related to a higher level of internalised stigma. Economic status was not significant. Thirty-five articles were included in the systematic review and clinical, psychological, psychosocial variables, cognition and sociodemographic factors were found to be associated with internalised stigma.

CONCLUSION

Internalised stigma in psychosis is ubiquitous worldwide and high collectivism culture may be related with high internalised stigma. With the presence of multiple individual factors related to internalised stigma, intervention programmes to reduce internalised stigma should consider focussing on both macro- and micro-level factors.

Time perspective and self-stigma in schizophrenia

BACKGROUND

Time perspective (TP) offers a new understanding of human personality, postulating that there are individual differences in how our mind assigns our experiences to different time categories. This concept may shed new light on the role of personality traits in shaping vulnerability to the internalized stigma.

AIM

In this paper we propose a novel approach to clarifying the underpinning of self-stigma by empirically exploring its links with TP.

METHOD

We conducted a cross-sectional study among 86 patients with ICD-10 diagnoses of paranoid schizophrenia to validate the predictive role of TP for self-stigma. We used the Zimbardo Time Perspective Inventory (ZTPI), Internalized Stigma of Mental Illness scale (ISMI) and Brief Psychiatric Rating Scale (BPRS).

RESULTS

We found significant positive correlations of self-stigma with Past-Negative, Future-Negative and Present-Fatalistic TP categories and negative correlation with the Future-Positive category. The hierarchical regression analyses revealed that two TP categories and Deviation from the Balanced Time Perspective (DBTP) are significant predictors of self-stigma over and above sociodemographic and clinical control variables. Conclusion. The results of the study confirm the hypothesis that TP opens new possibilities to understand proneness or resistance to self-stigmatization, and this may provide a basis for novel approaches to anti-self-stigma interventions.

Prevalence, risk, and protective factors of self-stigma for people living with depression: A systematic review and meta-analysis

BACKGROUND

People living with depression are subjected to widespread stigmatization worldwide. Self-stigma may negatively affect patients' treatment, recovery, and psychological well-being. This review aims to summarize and synthesize the evidence on the prevalence, risk, and protective factors of depression self-stigma.

METHODS

Four online databases, PubMed, PsycINFO, Web of Science, and Embase, were searched to identify eligible studies. Fifty-six studies involving a total of 11,549 samples were included in the final analysis. Four reviewers independently screened the literature, extracted data, and assessed the risk of bias in eligible studies. Pearson's r was chosen as the effect size metric of risk and protective factors.

RESULTS

The results showed that the global prevalence of depression self-stigma was 29 %. Levels of self-stigma varied across regions, but this difference was not significant. Two demographic factors were identified: ethnicity (r = 0.10, p < 0.05) and having a partner/married (r = -0.22, p < 0.001). Five risk factors were identified: depression severity (r = 0.33, p < 0.01), public stigma (r = 0.44, p < 0.001), treatment stigma (r = 0.46, p < 0.001), perceived stigma (r = 0.37, p < 0.001), and enacted stigma (r = 0.71, p < 0.001). Five protective factors were identified: quality of life (r = -0.38, p < 0.001), social relationship (r = -0.26, p < 0.05), self-esteem (r = -0.46, p < 0.001), extroversion (r = -0.32, p < 0.001), and social functioning (r = -0.49, p < 0.001).

LIMITATIONS

Heterogeneity was observed in some of the results. Causality cannot be inferred due to the predominance of cross-sectional designs among the included literature.

CONCLUSIONS

Risk and protective factors of depression self-stigma exist across many dimensions. Future research should examine the inner mechanisms and effectiveness of interventions to reduce stigma.

Maladaptive personality traits in patients with recent-onset psychosis: A case-control study using the Personality Inventory for the DSM-5 (PID-5)

BACKGROUND

The relationship between maladaptive personality traits and psychotic disorders in the early stages of disease has not been thoroughly investigated, even though it is essential for developing prevention and early intervention strategies.

METHODS

The five domains and the 25 facets of the Personality Inventory for DSM-5 (PID-5) were compared between 102 patients with recent-onset psychosis (ROP) and 116 community subjects (C) with a general linear model including age and sex in the analyses. In addition, multiple linear regression models were used to identify which factors associated with the PID-5 domains in ROP, and correlation analyses were used to explore the relationship between personality traits.

RESULTS

Patients with ROP, compared to C, exhibited higher scores in four out of the five domains with medium effect sizes (Cohen's f² ≥ 0.15) in two of them: negative affect (NA, p = 0.013, f² = 0.04), detachment (DET, p < 0.001, f² = 0.15), disinhibition (DIS, p < 0.001, f² = 0.14) and psychoticism (PSY, p < 0.001, f² = 0.16). Significant group differences were observed in 15 of the 25 facets and the largest effects were observed in the facets of withdrawal (p ≤ 0.001, f² = 0.20), irresponsibility (p < 0.001, f² = 0.23) and unusual beliefs (p = 0.001, f² = 0.22). Interestingly, being on antidepressants and high scores on the positive subscale of the Positive and Negative Syndrome Scale (PANSS) were associated with high scores of NA, antagonism (ANT) and PSY.

CONCLUSIONS

Maladaptive personality traits were prominent in persons with ROP. These findings suggest that personality traits might play a role in vulnerability to psychosis and highlight the importance of evaluating personality in the early stages of psychosis.

Personality traits in psychotic illness and their clinical correlates: A systematic review

This systematic review focuses on personality traits according to both the Five Factor Model and Cloninger Psychobiological Model in relation to treatment related outcome variables across all stages of clinical psychotic illness. Search of Pubmed and Psychinfo databases led to final inclusion of 65 studies, which were ranked on quality and analyzed according to the associations between personality and outcome. Main findings are that higher levels of Harm Avoidance and Neuroticism are associated with higher symptom levels, tendency towards passive coping, greater self-stigma, lower quality of life, and Harm Avoidance to higher suicidality. Higher levels of Extraversion and higher levels of Self-Directedness are associated with more preference for active coping, more intrinsic motivation and higher self-esteem. Higher Novelty Seeking is related to more substance use and aggression, in men specifically. On outcome of trauma, care consumption and duration of untreated illness no consistent associations with personality traits were found. Combined evidence from both personality models however reveals a consistent pattern of personality traits related to clinical outcome in psychotic disorder, which is discussed in a dimensional manner.

The clinical and psychosocial correlates of self-stigma among people with schizophrenia spectrum disorders across cultures: A systematic review and meta-analysis

BACKGROUND

Individuals with schizophrenia spectrum disorders (SSD) are at heightened risk of experiencing self-stigma, and some cultures are more stigmatizing towards SSD than others. The first purpose of this review is to provide an estimate of the relationship between self-stigma and clinical and psychosocial outcomes. The second purpose is to examine how these relationships vary across cultures.

METHOD

Studies reporting correlations between self-stigma and outcome variable(s) were identified through electronic database searches from June 1, 2021, to January 2, 2022. Mean effect sizes were calculated using Fisher's r-to-Z-transformation.

RESULTS

Sixty-three articles (N = 8925, 22 countries) were included in the systematic review and fifty-three articles (N = 7756) were included in the meta-analysis. For the most studied clinical correlates, self-stigma had a moderate, positive correlation with depressive symptoms (r = 0.49, p &lt; .001), a moderate, negative correlation with functioning (r = -0.39, p &lt; .001), and a positive, small correlation with severity of psychotic symptoms (r = 0.29, p &lt; .001), negative symptoms (r = 0.18, p &lt; .001) and positive symptoms (r = 0.13, p = .01). For the most studied psychosocial correlates, self-stigma had a strong, negative correlation with quality of life (r = -0.52, p &lt; .001) and self-esteem (r = -0.55, p &lt; .001). The correlates of self-stigma were similar across cultures.

DISCUSSION

Self-stigma shows strong to small correlations with clinical and psychosocial variables similarly across cultures. More research is needed to examine underlying mechanisms to develop effective interventions.

Affective temperaments of Lebanese patients with schizophrenia: comparison by gender and severity of psychosis

OBJECTIVES

Our aim in this study was to identify affective temperament differences utilizing the TEMPS-A in a large sample size of Lebanese patients with schizophrenia and compare them to healthy controls. Gender differences, demographic factors and degree of psychotic symptoms were also considered. A cross-sectional study was conducted at the Psychiatric Hospital of the Cross (PHC) from March to June 2019. Two-hundred fifty chronic patients with schizophrenia were compared to 250 healthy controls randomly chosen from the general population.

RESULTS

Patients with schizophrenia significantly had higher mean depressive, cyclothymic, irritable and anxious temperament scores compared to healthy controls. Healthy controls significantly had a higher mean hyperthymic temperament score compared to patients with schizophrenia. In the group of patients with schizophrenia exclusively, females scored higher in terms of depressive, cyclothymic and anxious temperaments compared to males. In the group of healthy controls, males scored higher in terms of hyperthymic and irritable temperaments compared to females, whereas a higher mean depressive and anxious temperament scores were significantly found in females compared to males. In addition, higher PANSS total scores, as well as higher positive, negative and general subscales scores were significantly associated with higher depressive, cyclothymic, irritable and anxious temperament scores.

Personality Factors Crucial in Internalized Stigma Understanding in Psychiatry

Objective: The main purpose of this research was to establish the relationship between personality traits and internalized stigma in individuals living with severe mental illness. Additionally, the study aimed to identify individual differences that could be used to develop the theoretical socio-cognitive-behavioral equation model of internalized stigma. Methods: A total of 114 patients with diagnosis of nonorganic psychotic disorder or uni- or bipolar affective disorder took part in this study. The Internalized Stigma of Mental Illness (ISMI) scale, Eysenck Personality Questionnaire Revised (EPQ-R) and NEO Five-Factor Inventory (NEO-FFI) were administrated among all participants. Results: Patients presenting higher levels of neuroticism scored higher on the ISMI scale. Otherwise, those with higher levels of extraversion, openness to experience and conscientiousness had lower ISMI scores. With the use of multivariate linear regression, neuroticism, openness to experience and conscientiousness showed the strongest associations with internalized stigma. Conclusions: Intrapersonal factors such as personality traits might explain individual differences in responses to the stigmatization process. Moreover, sociodemographic conditions such as the place of residence and level of education can play a mediating role in reducing the level of internalized stigma. Adequate psychosocial interventions should consider demographics and personality traits when engaging patients with mental illnesses in activities aimed at understanding and accepting the disorders.

The Influence of Body Image, Insight, and Mental Health Confidence on Medication Adherence in Young Adult Women with Mental Disorders

The aim of this descriptive study was to investigate the impact of body image, insight, and mental health confidence on medication adherence among young adult women with mental disorders. Data collection occurred from August to September 2018. The study participants were 147 young adult women aged 19 to 45 with mental disorders who were psychiatry outpatients either getting treatment in general hospitals located in Seoul and Gyeonggi Province or receiving rehabilitation therapy through local mental health welfare centers in Korea, and agreed to participate in the study. The measurement tools used were the Body Image Scale; the Scale to Assess Unawareness of Mental Disorder, Korean short-form version; the Korean version of the Mental Health Confidence Scale; and the Korean version of the Medication Compliance Scale. The collected data were analyzed using descriptive statistics, t-test, analysis of variance, Pearson correlation analysis, and multiple regression analysis in SPSS/WIN 25.0 (IBM Corp., Armonk, NY, USA). Medication adherence among the study participants differed by age (F = 2.95, p = 0.042), religion (t = −2.06, p = 0.042), level of trust in psychiatrists (F = 5.40, p = 0.006), treatment duration (F = 4.48, p = 0.005), and noncompliance to medication regimens due to weight gain (t = −2.61, p = 0.010). Multiple regression analysis demonstrated that body image (β = −0.32, p < 0.001), insight (β = −0.24, p = 0.002), and mental health confidence (β = 0.24, p = 0.004) had a significant impact on the medication adherence of the participants. Body image, in particular, had the greatest influence on the medication adherence of the participants. This study found that body image, insight, and mental health confidence were important in improving medication adherence among young adult women with mental disorders. Practical, patient-centered, and individualized approaches that can improve medication adherence by seeking to understand negative perceptions regarding body image should be considered.

Association Between Autistic Symptoms and Self-Stigma in Patients with Schizophrenia Spectrum Disorders

PURPOSE

Self-stigma negatively influences self-esteem, quality of life, self-efficacy, treatment adherence, and recovery in psychiatric patients. By revealing personality traits that influence self-stigma, we can gain useful knowledge for the management of self-stigma. A previous meta-analysis indicated that patients with schizophrenia have higher scores on the Autism-Spectrum Quotient (AQ) than healthy controls. However, the relationship between autistic symptoms and self-stigma in patients with schizophrenia spectrum disorders remains unclear. Therefore, the present study aimed to reveal the association between autistic symptoms and self-stigma in patients with schizophrenia spectrum disorders.

PATIENTS AND METHODS

We recruited 127 patients with schizophrenia spectrum disorders (schizophrenia, schizoaffective disorder, and delusional disorder). We assessed participants' self-stigma and autistic symptoms using the Internalized Stigma for Mental Illness (ISMI) scale and the Autism-Spectrum Quotient (AQ), respectively. The differences in the scores of ISMI and AQ according to patient characteristics were investigated. Multiple regression analysis controlling for age and gender was performed to determine the relationship between the total scores on the AQ and IMSI scale.

RESULTS

Female patients showed a higher level of self-stigma than males. Unmarried patients showed a significantly higher score on the AQ than married patients. Multiple regression analysis adjusted for age and gender indicated that the total score on AQ might be a predictor of the overall rating on ISMI in patients with schizophrenia spectrum disorders.

CONCLUSION

This study is the first to reveal the association between autistic symptoms and self-stigma in patients with schizophrenia spectrum disorders. Our results highlight the importance of considering autistic symptoms in the assessment and management of self-stigma in patients with schizophrenia spectrum disorders.

Factors influencing the level of self-stigmatisation in people with mental illness

AIM

The aim of this study was to assess sociodemographic factors and factors connected with treatment of mental illness and to decide whether they can influence the level of self-stigma.

METHOD

Sociodemographic characteristics (age, gender, family status, level of employment, level of education) and characteristics related to illness and treatment (diagnosis, length of treatment, adherence to treatment) were gathered in a group of patients in stable mental condition, without acute symptoms of mental illness. Self-stigma was measured using the Self-stigma of Mental Illness Scale - short form (SSMIS-SF).

RESULTS

The sample included 197 patients: 99 patients in group 1 (G1) with psychosis and 98 in group 2 (G2) with anxious and affective disorders. The average age was 44.15 ± 12.91 years, the length of illness was 11.67 ± 9.21 years and 48% of patients were men. The total average SSMIS-SF score was 61.54 ± 23.34. We found no statistically significant difference in the total level of self-stigmatisation between these groups ( t(197) = 0.77; p = .441). The level of self-stigmatisation (total score of SSMIS-SF) in patients in G1 (psychosis) increased with the length of illness r(99) = .253; p = .011. Employment status seems to correlate with the level of self-stigmatisation ( F(3, 184) = 5.27; p = .002). Patients unemployed and on disability pension had higher levels of self-stigmatisation than patients working full-time. Patients who took medication regularly (full medical adherence) had lower scores of SSMIS-SF total scores in comparison with patients with lower compliance ( t(195) = 3.476; p = .001; Cohen's d = .25).

CONCLUSION

According to our results, with regard to the factors that were followed, self-stigmatisation correlates with the presence of employment (social inclusion), duration of illness in patients with psychosis and treatment adherence. We did not find a statistically significant influence of age, gender, marital status or clinical diagnosis on the level of self-stigma.

Individual factors that influence experiences and perceptions of stigma and discrimination towards people with mental illness in Ghana

People with a mental illness often encounter stigma and discrimination from a variety of sources, reinforcing negative self-perceptions and influencing their health and well-being. Even though support systems and attitudes of the general public act as powerful sources of stigma, views and perceptions held by people with mental illness also influence their sensitivity to the experiences they encounter. The aim of the present qualitative study was to examine perceptions of stigma and discrimination and self-stigma in individuals diagnosed with a mental illness. This study adopted a narrative, descriptive method, using a semistructured interview guide to elicit participant perceptions regarding sources of stigma, discrimination, and personal factors that might influence their experiences. Twelve outpatients attending a clinic in Ghana were interviewed. Thematic content analysis was completed and augmented by field notes. Participants' perceptions about personal impacts of stigma were found to be influenced by self-stigma, anticipated stigma and discrimination, perceived discrimination, and their knowledge about their illness. For many participants, their views served to augment societal views, and thus reinforce negative self-perceptions and their future. However, for other participants, their views served as a buffer in the face of environmental situations that reflect stigma and discrimination. Stigma is a complex, socially-sanctioned phenomenon that can seriously affect the health of people with mental illness. As such, it requires coordinated strategies among public policy makers, governmental bodies, and health-care providers to address stigma on a societal level, and to address its potential impacts on broad health outcomes for individuals with mental illness.

Internalized stigma in psoriasis: A multicenter study

Internalized stigma is the adoption of negative attitudes and stereotypes of the society regarding a person's illness. It causes decreased self-esteem and life-satisfaction, increased depression and suicidality, and difficulty in coping with the illness. The primary aim of this study was to investigate the internalized stigma state of psoriatic patients and to identify the factors influencing internalized stigma. The secondary aim was to identify the correlation of internalized stigma with quality of life and perceived health status. This multicentre, cross-sectional study comprised 1485 patients. There was a significant positive correlation between mean values of Psoriasis Internalized Stigma Scale (PISS) and Psoriasis Area and Severity Index, Body Surface Area, Dermatological Life Quality Index and General Health Questionnaire-12 (P < 0.001 in all). Lower percieved health score (P = 0.001), early onset psoriasis (P = 0.016), family history of psoriasis (P = 0.0034), being illiterate (P < 0.001) and lower income level (P < 0.001) were determinants of high PISS scores. Mean PISS values were higher in erythrodermic and generalized pustular psoriasis. Involvement of scalp, face, hand, genitalia and finger nails as well as arthropathic and inverse psoriasis were also related to significantly higher PISS scores (P = 0.001). Our findings imply that psoriatic patients experience high levels of internalized stigma which are associated with psoriasis severity, involvement of visible body parts, genital area, folds or joints, poorer quality of life, negative perceptions of general health and psychological illnesses. Therefore, internalized stigma may be one of the major factors responsible from psychosocial burden of the disease.

Quality of life, self-stigma, and hope in schizophrenia spectrum disorders: a cross-sectional study

GOALS

The aim of this study was to explore the quality of life, self-stigma, personality traits, and hope in patients with schizophrenia spectrum disorders.

PATIENTS AND METHODS

A total of 52 outpatients participated in this cross-sectional study. The attending psychiatrist assessed each patient with Mini International Neuropsychiatric Interview (MINI). The patients then completed Quality of Life Satisfaction and Enjoyment Questionnaire (Q-LES-Q), Internalized Stigma of Mental Illness (ISMI) Scale, Temperament and Character Inventory - Revised (TCI-R), Adult Dispositional Hope Scale (ADHS), Drug Attitude Inventory 10 (DAI-10), and Liebowitz Social Anxiety Scale (LSAS)-Self-report. The psychiatrist evaluated Clinical Global Impression Severity - the objective version (objCGI-S), and the patients completed the Clinical Global Impression Severity - the subjective version (subjCGI-S). Each participant also completed Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI).

RESULTS

The quality of life was significantly higher in employed patients and individuals with higher hope, self-directedness (SD), and persistence (PS). The quality of life was lower among patients with higher number of psychiatric hospitalizations, those with higher severity of the disorder, and individuals who were taking higher doses of antipsychotics. Patients with more pronounced symptoms of depression, anxiety, and social anxiety had a lower quality of life. Finally, the quality of life was lower among individuals with higher harm avoidance (HA) and self-stigmatization (ISMI). Backward stepwise regression was applied to identify the most significant factors connected to self-stigma. The regression analysis showed that occupation, level of depression (BDI-II), attitude to using medication (DAI-10), social anxiety (LSAS), and antipsychotic index were the most relevant factors associated with lower quality of life.

CONCLUSION

Detection of the quality of life in the context of personality traits, hope, self-stigma, and demographic and clinical factors may be an important part of the assessment of the patient with schizophrenia.

Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months

We investigated the relationship between internalized stigma of mental illness at baseline and depressive and psychotic symptoms 3 and 6 months later, controlling for baseline symptoms. Data on homeless veterans with severe mental illness (SMI) were provided by the Northeast Program Evaluation Center (NEPEC) Special Needs-Chronic Mental Illness (SN-CMI) study (Kasprow and Rosenheck, 2008). The study used the Internalized Stigma of Mental Illness (ISMI) scale to measure internalized stigma at baseline and the Symptom Checklist-90-R (SCL-90-R) to measure depressive and psychotic symptoms at baseline and 3 and 6 month follow-ups. Higher levels of internalized stigma were associated with greater levels of depressive and psychotic symptoms 3 and 6 months later, even controlling for symptoms at baseline. Alienation and Discrimination Experience were the subscales most strongly associated with symptoms. Exploratory analyses of individual items yielded further insight into characteristics of potentially successful interventions that could be studied. Overall, our findings show that homeless veterans with SMI experiencing higher levels of internalized stigma are likely to experience more depression and psychosis over time. This quasi-experimental study replicates and extends findings of other studies and has implications for future controlled research into the potential long-term effects of anti-stigma interventions on mental health recovery.

Evidence for the indirect effects of perceived public stigma on psychosocial outcomes: The mediating role of self-stigma

This study examined the possible mediating role of self-stigma in the relationship between perceived public stigma and psychosocial outcomes and how this mechanism may be contingent on illness severity in a non-Western (Chinese) sample. A total of 251 participants, namely 151 psychiatric outpatients with psychotic disorders and 100 psychiatric outpatients without psychotic disorders, completed a questionnaire on stigma and psychosocial outcomes that covered topics such as self-esteem, depressive symptoms, and subjective quality of life (QoL). Using a cross-sectional design, ordinary least squares regression and bootstrapping mediation analyses were used to test whether self-stigma mediated the relationship between perceived public stigma and psychosocial outcomes and whether this mediating process was moderated by diagnostic status. The results indicated that self-stigma mediated the effect of perceived public stigma on psychosocial outcomes such as self-esteem, depressive symptoms, and subjective QoL among both patients with psychotic disorders and those without psychotic disorders after controlling for demographic and clinical characteristics. Further, moderated mediation analyses revealed that the indirect effect of perceived public stigma on psychosocial outcomes were not moderated by the status of psychotic diagnoses. Self-stigma might be an essential and tractable target for interventions aimed at breaking the vicious cycle of discrimination and stigmatization toward people with mental illness regardless of their diagnoses.

Characteristics, correlates and outcomes of perceived stigmatization in bipolar disorder patients

BACKGROUND

The aim of this study was to elucidate the characteristics, correlates and outcomes of perceived stigmatization in patients with Bipolar Disorder (BD).

METHODS

At baseline 50 remitted BD patients completed the Stigma Questionnaire (SQ), the Work and Social Adjustment Scale (WSAS), and the Temperament Evaluation of the Memphis, Pisa, Paris and San Diego Auto-Questionnaire - Short Version (TEMPS-A). The BD patients were followed for 24 months as part of their ongoing treatment. Information on illness course and treatments was obtained at baseline and at follow-up through medical records and interviews.

RESULTS

The prevalence of perceived stigmatization ranged from 37% to 57% across the areas measured by the SQ. The areas with most perceived stigmatization were work-ability and psychiatric hospitalization. Psychoeducation and affective temperaments emerged as significant independent predictors of perceived stigmatization. Perceived stigmatization was not related to affective recurrences.

LIMITATIONS

The follow-up period might have been too short to measure the long-term impact of perceived stigmatization.

CONCLUSIONS

The findings suggest that BD patients consider issues concerning work-ability and psychiatric hospitalizations to be particularly affected by stigmatization. Psychoeducation and affective temperaments were, furthermore, identified as factors implicated in perceived stigmatization in this population.

Psychological Distress Increases Perceived Stigma Toward Attempted Suicide Among Those With a History of Past Attempted Suicide

People who suffer from mental illness have high self-stigmatizing attitudes. This study aims to test the effect of psychopathological distress on stigma toward attempted suicide in a population of suicide attempters. Data were collected through an interview and 2 questionnaires (90-item Symptom Checklist; Stigma of Suicide Attempt scale) administered to 67 patients hospitalized after an attempted suicide. Participants with a history of past attempted suicide had higher scores on the Stigma of Suicide Attempt scale (t58.9 = -2.51, p = 0.014). Higher levels of psychological distress were related to greater perceived stigma only in individuals with a history of past attempted suicide (standardized coefficient = 0.37; t = 2.36; p = 0.024; R2 = 14%; adjusted R2 = 11.5%). A previous experience of attempted suicide is related to greater self-stigmatizing attitudes toward suicidal behavior. Among those who have previously attempted suicide in particular, psychopathological distress may significantly contribute to increase the perception of stigma.

Psychological factors and treatment effectiveness in resistant anxiety disorders in highly comorbid inpatients

BACKGROUND

Anxiety disorders are a group of various mental syndromes that have been related with generally poor treatment response. Several psychological factors may improve or hinder treatment effectiveness. Hope has a direct impact on the effectiveness of psychotherapy. Also, dissociation is a significant factor influencing treatment efficiency in this group of disorders. Development of self-stigma could decrease treatment effectiveness, as well as several temperamental and character traits. The aim of this study was to explore a relationship between selected psychological factors and treatment efficacy in anxiety disorders.

SUBJECTS AND METHODS

A total of 109 inpatients suffering from anxiety disorders with high frequency of comorbidity with depression and/or personality disorder were evaluated at the start of the treatment by the following scales: the Mini-International Neuropsychiatric Interview, the Internalized Stigma of Mental Illness scale, the Adult Dispositional Hope Scale, and the Temperament and Character Inventory - revised. The participants, who sought treatment for anxiety disorders, completed the following scales at the beginning and end of an inpatient-therapy program: Clinical Global Impression (objective and subjective) the Beck Depression Inventory - second edition, the Beck Anxiety Inventory, and the Dissociative Experiences Scale. The treatment consisted of 25 group sessions and five individual sessions of cognitive behavioral therapy or psychodynamic therapy in combination with pharmacotherapy. There was no randomization to the type of group-therapy program.

RESULTS

Greater improvement in psychopathology, assessed by relative change in objective Clinical Global Impression score, was connected with low initial dissociation level, harm avoidance, and self-stigma, and higher amounts of hope and self-directedness. Also, individuals without a comorbid personality disorder improved considerably more than comorbid patients. According to backward-stepwise multiple regression, the best significant predictor of treatment effectiveness was the initial level of self-stigma.

CONCLUSION

The initial higher levels of self-stigma predict a lower effectiveness of treatment in resistant-anxiety-disorder patients with high comorbidity with depression and/or personality disorder. The results suggest that an increased focus on self-stigma during therapy could lead to better treatment outcomes.

Self-stigma in borderline personality disorder - cross-sectional comparison with schizophrenia spectrum disorder, major depressive disorder, and anxiety disorders

INTRODUCTION

Self-stigma arises from one's acceptance of societal prejudices and is common in psychiatric patients. This investigation compares the self-stigma of a sample of patients with borderline personality disorder (BPD), schizophrenia spectrum disorder (SCH), major depressive disorder (MDD), bipolar affective disorder (BAD), and anxiety disorders (AD) and explores of the self-stigma with the subjective and objective measures of the severity of the disorder and demographic factors.

METHODS

The total of 184 inpatients admitted to the psychotherapeutic department diagnosed with BPD, SCH, MDD, BAP, and AD were compared on the internalized stigma of mental illness (ISMI) scale. The ISMI-total score was correlated with the subjective and objective evaluation of the disorder severity (clinical global impression), and clinical and demographic factors.

RESULTS

The self-stigma levels were statistically significantly different among the diagnostic groups (BPD 71.15±14.74; SCH 63.2±13.27; MDD 64.09±12.2; BAD 62.0±14.21; AD 57.62±15.85; one-way analysis of variance: F=8.698, df=183; P<0.005). However after applying the Bonferroni's multiple comparison test, the only significant difference was between the BPD patients and the patients with AD (P<0.001). Stepwise regression analysis showed that the strongest factors connected with the higher level of self-stigma were being without partner, the number of hospitalization, and the severity of the disorder.

CONCLUSION

The BPD patients suffer from a higher level of self-stigma compared to patients with AD. In practice, it is necessary to address the reduction of self-stigma by using specific treatment strategies, such as cognitive therapy.

Relationship between personality traits and perceived internalized stigma in bipolar patients and their treatment partners

Internalized stigma of mental disorders has significant negative outcomes for patients with bipolar disorder and their families. The aim of this study is to evaluate the association between personality traits and internalized stigma of mental disorders in bipolar patients and their treatment partners. Five different questionnaires were utilized in this study: (1) Demographic data questionnaire, (2) Millon Clinical Multiaxial Inventory-III (MCMI-III) for personality traits, (3) Internalized Stigma of Mental Illness (ISMI) for stigma, (4) Self Report Manic Inventory (SRMI) for mania and (5) Center for Epidemiological Studies-Depression Scale (CES-D) for depression. The scores of personality traits were combined to create externalizing and internalizing personality trait scores. Results showed that patients with bipolar disorder and their treatment partners both experienced internalized stigma of mental health disorders. There was a significant positive correlation between internalized stigma and internalizing personality traits, but not externalizing traits. In a multi-variate regression analysis, internalizing personality trait score was found to be a significant predictor of internalized stigma. In conclusion, patients with bipolar disorder and their treatment partners perceive higher level of internalized stigma of mental disorders if they have internalizing personality traits.

Bipolar disorder and self-stigma: A comparison with schizophrenia

AIM

Even though numerous studies have focused on the effects of self-stigma on patients with schizophrenia, little is known about self-stigma of patients with bipolar disorder (BD). In this study, a self-administered scale of self-stigmatising attitudes of patients with BD and schizophrenia was used to explore these attitudes, examine the potential differences between the two groups and study the factors that influence stigma within groups.

METHODS

Self-stigma of 120 patients with schizophrenia and BD was assessed with the Self-stigma Questionnaire (SSQ) and the Stigma Inventory for Mental Illness (SIMI). Presence of clinical symptoms, overall functioning and level of self-esteem were also evaluated.

RESULTS

Self-stigma is present in both groups but differs in its intensity. Patients with BD experience self-stigma in a lesser degree without affecting their social life or overall functioning. Patients with schizophrenia adopt more intense self-stigmatising attitudes leading to social exclusion and lower level of overall functioning.

LIMITATIONS

The results are limited by the small sample size, whereas the inclusion of other questionnaires would broaden our insight to self-stigma.

CONCLUSIONS

Self-stigma has a direct effect on overall functioning of patients with BD and schizophrenia tampering the clinical outcome of therapeutic interventions. Therefore, it should be incorporated in every treatment plan and be addressed as a clinical symptom of the mental illness.

Individual correlates of self-stigma in patients with anxiety disorders with and without comorbidities

BACKGROUND

A number of psychiatric patients experience stigma connected to prejudices about mental disorders. It has been shown that stigma is most harmful when it is internalized. Most of the studies were performed on individuals either with psychoses or with mood disorders, and hence, there are almost no studies with other diagnostic categories. The goals of this research were to identify factors that are significantly related to self-stigma in patients with anxiety disorders and to suggest possible models of causality for these relationships.

METHODS

A total of 109 patients with anxiety disorders and possible comorbid depressive or personality disorders, who were admitted to the psychotherapeutic department participated in this study. All patients completed several psychodiagnostic methods, ie, the Internalized Stigma of Mental Illness Scale, Temperament and Character Inventory-Revised Version, Adult Dispositional Hope Scale, Dissociative Experiences Scale, Beck Anxiety Inventory, Beck Depression Inventory-Second Edition, and Clinical Global Impression (also completed by the senior psychiatrist).

RESULTS

The overall level of self-stigma was positively associated with a comorbid personality disorder, more severe symptomatology, more intense symptoms of anxiety and depression, and higher levels of dissociation and harm avoidance. Self-stigma was negatively related to hope, reward dependence, persistence, self-directedness, and cooperativeness. Multiple regression analysis showed that the most significant factors connected to self-stigma are harm avoidance, the intensity of depressive symptoms, and self-directedness. Two models of causality were proposed and validated. It seems that the tendency to dissociate in stress increases the probability of development of self-stigma, and this relationship is entirely mediated by avoidance of harm. Conversely, self-directedness lowers the probability of occurrence of self-stigma, and this effect is partly mediated by hope.

CONCLUSION

Patients with anxiety disorders accompanied with or without comorbid depressive or personality disorders may suffer from self-stigma. Individuals with greater sensitivity to rejection and other socially aversive stimuli are prone to the development of self-stigma. Other personality factors, such as hopeful thinking and self-acceptance serve as factors promoting resilience concerning self-stigma.

Internalized stigma and its psychosocial correlates in Korean patients with serious mental illness

We aimed to examine internalized stigma of patients with mental illness in Korea and identify the contributing factors to internalized stigma among socio-demographic, clinical, and psychosocial variables using a cross-sectional study design. A total of 160 patients were recruited from a university mental hospital. We collected socio-demographic data, clinical variables and administered self-report scales to measure internalized stigma and levels of self-esteem, hopelessness, social support, and social conflict. Internalized stigma was identified in 8.1% of patients in our sample. High internalized stigma was independently predicted by low self-esteem, high hopelessness, and high social conflict among the psychosocial variables. Our finding suggests that simple psychoeducation only for insight gaining cannot improve internalized stigma. To manage internalized stigma in mentally ill patients, it is needed to promote hope and self-esteem. We also suggest that a relevant psychosocial intervention, such as developing coping skills for social conflict with family, can help patients overcome their internalized stigma.

Opinions of forensic schizophrenia patients on the use of restraints: controversial legislative issues

The use of restraints is a controversial issue even though legal regulations may seem straightforward. Our aims were to evaluate the forensic patients' opinions on certain aspects of restraining and to compare these opinions with the current legal norms. Inpatients with schizophrenia or schizoaffective disorder at the Department of Forensic Psychiatry in Popovača, Croatia, were asked the following questions about the use of mechanical restraints: (a) Should the patients' family be informed about the use of restraints? (b) Should the physician ask the patient whether to inform the family about the use of restraints? (c) Can the use of restraints be a kind of punishment for intentionally aggressive behavior toward people in their environment? and (d) Should restraints be used if the patient requests to be restrained? The patients were assessed according to the Temperament and character inventory and Positive and Negative Symptom Scale. Fifty-four forensic patients with a history of serious offences were included in the study. Their average age was 44.7 (± 8.39) years and the mean duration of their treatment was 6.6 (± 5.08) years. There was no predominant opinion on sharing the information with the family, but there was a relationship between the opinions and psychopathology and personality. Regardless of the patients' mental state and personality, the opinions on the voluntary use of restraints and the use of restraints as punishment for intentionally aggressive behavior were mainly positive. The patients' opinions suggest a need for the implementation of more specific guidelines in the area of forensic psychiatry.

Aspects of perceived stigma: the Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties

OBJECTIVE

The aim of this study was to develop a new brief and easy to administer self-stigma scale for mental illness as well as to assess the correlations between self-stigma and psychopathology of chronic schizophrenic patients.

METHODS

The Stigma Inventory for Mental Illness (SIMI) was administered to 100 outpatients diagnosed with schizophrenia. Psychopathology and overall functioning were assessed with the Positive and Negative Symptom Scale (PANSS) and Global Assessment Scale (GAS), respectively.

RESULTS

The final scale consists of 12 items. Factor analysis concluded to two dimensions: perceptions of social stigma and self-efficacy. Both factors were found to be reliable (high internal consistency and stability coefficients). Significant correlations were present with psychopathology, functioning and selected items from the Community Attitudes toward the Mentally Ill (CAMI) inventory.

CONCLUSION

The SIMI scale is a reliable and valid psychometric tool that can be used to assess patient's self-stigma and self-efficacy. The findings suggest also that psychopathology has an immediate effect on endorsing self-stigmatizing attitudes.

Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia

This study investigated the associations between internalized stigma, depressive symptoms, and temperament dimension Harm avoidance. One hundred and seventeen stable outpatients with schizophrenia completed a battery of self-report instruments. Internalized stigma was significantly positively related to depressive symptoms, while Harm avoidance moderated the internalized stigma-depressive symptoms relationship.

Temperament and character in remitted and symptomatic patients with schizophrenia: modulation by the COMT Val158Met genotype

While research on remission in schizophrenia has gained attention, personality characteristics associated with remission in schizophrenia have been under-studied. A functional valine-to-methionine (Val158Met) polymorphism in the catechol-O-methyltransferase (COMT) gene is shown to modify clinical presentation of schizophrenia despite weak or no association with the disorder itself. Studies also report that this polymorphism can affect personality traits. We aimed to examine personality traits of remitted patients with schizophrenia as compared to symptomatic patients and healthy controls and to investigate whether the COMT Val158Met polymorphism influences their personality. Scores on the Temperament and Character Inventory were compared between 34 remitted outpatients with schizophrenia, age- and sex-matched 72 symptomatic outpatients with schizophrenia, and matched 247 healthy individuals. The effect of COMT Val158Met polymorphism on personality was examined in each group. The analysis of covariance, controlling for confounding variables, revealed that compared to healthy controls, symptomatic patients exhibited a pervasively altered personality profile whereas remitted patients showed alterations in more limited personality dimensions and demonstrated normal levels of novelty-seeking, reward dependence and cooperativeness. The two-way analysis of covariance, with genotype and sex as between-subject factors and confounders as covariates, revealed that Met carriers demonstrated significantly lower reward dependence and cooperativeness than Val homozygotes in symptomatic patients; while no significant genotype effect was found in remitted patients or in healthy individuals. These findings indicate that remitted patients with schizophrenia have a relatively adaptive personality profile compared to symptomatic patients. The COMT Val158Met polymorphism might have a modulating effect on the relationship between personality and remission.

Internalized Stigma of Mental Illness (ISMI) scale: a multinational review

The Internalized Stigma of Mental Illness (ISMI) scale is a 29-item questionnaire measuring self-stigma among persons with psychiatric disorders. It was developed with substantial consumer input and has been widely used, but its psychometric qualities have not been comprehensively evaluated across multiple versions. Here we review the 55 known versions, and provide the 47 available versions, including: Arabic, Armenian, Bengali, Bulgarian, Chinese (Mainland, Taiwan, Hong Kong), Croatian, Dutch, English (USA, South Africa), Estonian, Farsi, Finnish, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Lithuanian, Lugandan, Maltese, Polish, Portuguese (Portugal, Brazil), Romanian, Russian, Samoan, Slovenian, Spanish (Spain), Swahili, Swedish, Tongan, Turkish, Urdu, and Yoruba, and qualitative English and Swahili versions, as well as versions for depression, schizophrenia, substance abuse, eating disorders, epilepsy, inflammatory bowel disease, leprosy, smoking, parents and caregivers of people with mental illness, and ethnicity. The various versions show reliability and validity across a wide range of languages, cultures, and writing systems. The most commonly reported findings of studies using the ISMI are that internalized stigma correlates with higher depression, lower self esteem, and higher symptom severity. Initial studies of ways to reduce internalized stigma are promising and warrant further investigation.

Internalized stigma and intimate relations in bipolar and schizophrenic patients: a comparative study

OBJECTIVE

The aim of this study was to determine characteristics of internalized stigma and intimate relations in bipolar and schizophrenia patients and to compare characteristics of intimate relations in bipolar and schizophrenia patients with or without internalized stigma.

METHOD

A total of 228 volunteers were included, 119 patients with bipolar disorder and 109 with schizophrenia. Schizophrenic and bipolar disorder patients were compared in terms of internalized stigma and intimate relations characteristics. Bipolar and schizophrenia patients with and without internalized stigma were compared in terms of characteristics of intimate relations.

RESULTS

Internalized stigma was determined in one in three schizophrenia and one in five bipolar patients. Stigma resistance and relational esteem in intimate relations scores were higher in bipolar patients. Relational anxiety/fear of relationship, relational monitoring and external relational control scores were higher in schizophrenia patients with internalized stigma compared to those without, while their relational satisfaction, relational esteem and relational assertiveness scores were lower. Relational anxiety/fear of relationship and relational monitoring scores were higher in bipolar patients with internalized stigma compared to those without, while their relational satisfaction scores were lower.

CONCLUSION

Internalized stigma in schizophrenia patients is a well-known subject that has been investigated previously. The results of our study are significant in terms of showing that internalized stigma is also frequent in bipolar disorder patients, and not solely in schizophrenia patients. Stigma resistance is higher in bipolar disorder patients. Internalized stigma is correlated with intimate relations in both bipolar and schizophrenia patients.

Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions

A systematic electronic PubMed, Medline and Web of Science database search was conducted regarding the prevalence, correlates, and effects of personal stigma (i.e., perceived and experienced stigmatization and self-stigma) in patients with schizophrenia spectrum disorders. Of 54 studies (n=5,871), published from 1994 to 2011, 23 (42.6%) reported on prevalence rates, and 44 (81.5%) reported on correlates and/or consequences of perceived or experienced stigmatization or self-stigma. Only two specific personal stigma intervention studies were found. On average, 64.5% (range: 45.0-80.0%) of patients perceived stigma, 55.9% (range: 22.5-96.0%) actually experienced stigma, and 49.2% (range: 27.9-77.0%) reported alienation (shame) as the most common aspect of self-stigma. While socio-demographic variables were only marginally associated with stigma, psychosocial variables, especially lower quality of life, showed overall significant correlations, and illness-related factors showed heterogeneous associations, except for social anxiety that was unequivocally associated with personal stigma. The prevalence and impact of personal stigma on individual outcomes among schizophrenia spectrum disorder patients are well characterized, yet measures and methods differ significantly. By contrast, research regarding the evolution of personal stigma through the illness course and, particularly, specific intervention studies, which should be conducted utilizing standardized methods and outcomes, are sorely lacking.