Prediction of methylphenidate treatment outcome in adults with attention-deficit/hyperactivity disorder (ADHD)

Compulsory admission to psychiatric inpatient treatment can be experienced as disempowering and stigmatizing by people with serious mental illness. However, quantitative studies of stigma-related emotional and cognitive reactions to involuntary hospitalization and their impact on people with mental illness are scarce. Among 186 individuals with serious mental illness and a history of recent involuntary hospitalization, shame and self-contempt as emotional reactions to involuntary hospitalization, the cognitive appraisal of stigma as a stressor, self-stigma, empowerment as well as quality of life and self-esteem were assessed by self-report. Psychiatric symptoms were rated by the Brief Psychiatric Rating Scale. In multiple linear regressions, more self-stigma was predicted independently by higher levels of shame, self-contempt and stigma stress. A greater sense of empowerment was related to lower levels of stigma stress and self-contempt. These findings remained significant after controlling for psychiatric symptoms, diagnosis, age, gender and the number of lifetime involuntary hospitalizations. Increased self-stigma and reduced empowerment in turn predicted poorer quality of life and reduced self-esteem. The negative effect of emotional reactions and stigma stress on quality of life and self-esteem was largely mediated by increased self-stigma and reduced empowerment. Shame and self-contempt as reactions to involuntary hospitalization as well as stigma stress may lead to self-stigma, reduced empowerment and poor quality of life. Emotional and cognitive reactions to coercion may determine its impact more than the quantity of coercive experiences. Interventions to reduce the negative effects of compulsory admissions should address emotional reactions and stigma as a stressor.     

A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal

Stigma can be a major stressor for individuals with schizophrenia and other mental illnesses. It is unclear, however, why some stigmatized individuals appraise stigma as more stressful, while others feel they can cope with the potential harm posed by public prejudice. We tested the hypothesis that the level of perceived public stigma and personal factors such as rejection sensitivity, perceived legitimacy of discrimination and ingroup perceptions (group value; group identification; entitativity, or the perception of the ingroup of people with mental illness as a coherent unit) predict the cognitive appraisal of stigma as a stressor. Stigma stress appraisal refers to perceived stigma-related harm exceeding perceived coping resources. Stress appraisal, stress predictors and social cue recognition were assessed in 85 people with schizophrenia, schizoaffective or affective disorders. Stress appraisal did not differ between diagnostic subgroups, but was positively correlated with rejection sensitivity. Higher levels of perceived societal stigma and holding the group of people with mental illness in low regard (low group value) independently predicted high stigma stress appraisal. These predictors remained significant after controlling for social cognitive deficits, depressive symptoms and diagnosis. Our findings support the model that public and personal factors predict stigma stress appraisal among people with mental illness, independent of diagnosis and clinical symptoms. Interventions that aim to reduce the impact of stigma on people with mental illness could focus on variables such as rejection sensitivity, a personal vulnerability factor, low group value and the cognitive appraisal of stigma as a stressor.     

Stigma-related stress,shame and avoidant coping reactions among members of the general population with elevated symptom levels

BackgroundIt is unclear whether mental illness stigma affects individuals with subthreshold syndromes outside clinical settings. We therefore investigated the role of different stigma variables, including stigma-related stress and shame reactions, for avoidant stigma coping among members of the general population with elevated symptom levels.MethodsBased on a representative population survey, general stress resilience, stigma variables, shame about having a mental illness as well as avoidant stigma coping (secrecy and social withdrawal) were assessed by self-report among 676 participants with elevated symptom levels. Stigma variables and resilience were examined as predictors of avoidant stigma coping in a path model.ResultsIncreased stigma stress was predicted by lower general stress resilience as well as by higher levels of perceived stigma, group identification and perceived legitimacy of discrimination. More shame was associated with higher perceived legitimacy. Lower resilience as well as more perceived stigma, group identification and perceived legitimacy predicted avoidant coping. Stigma stress partly mediated effects of resilience, perceived stigma and group identification on avoidant coping; shame partly mediated effects of perceived legitimacy on coping. Stigma stress and shame were also directly and positively related to avoidant stigma coping. Analyses were adjusted for symptoms, neuroticism and sociodemographic variables.ConclusionsStigma may affect a larger proportion of the population than previously thought because stigma variables predicted secrecy and withdrawal among members of the general population with elevated, but overall mild symptom levels. Avoidant stigma coping likely has harmful effects, potentially exacerbating pre-existing psychological distress and undermining social networks. This highlights the need to reduce public stigma as well as to support individuals with subthreshold syndromes in their coping with stigma stress and shame reactions.     

Self-stigma, empowerment, and perceived legitimacy of discrimination among women with mental illness

OBJECTIVE: The study sought to better understand why some people with mental illness self-stigmatize and develop low self-esteem while others remain indifferent to stigma or respond with a sense of empowerment. The authors hypothesized that a high level of perceived discrimination, little sense of identification with the group of people with mental illness, and a high level of perceived legitimacy of discrimination lead to self-stigma. METHODS: Sixty women with borderline personality disorder and 30 women with social phobia, who were recruited at three centers in Germany and Switzerland, completed stigma-related questionnaires. RESULTS: After depression and index diagnosis were controlled for, a low level of perceived discrimination and of the legitimacy of discrimination predicted high self-esteem and high empowerment. Identification with the group of people with mental illness did not predict self-esteem or empowerment. CONCLUSIONS: Perceived legitimacy of discrimination may be a crucial determinant of a person's response to stigma.     

An admixture analysis of the age at index episodes in bipolar disorder

Similar to members of the public, people with mental illness may exhibit general negative automatic prejudice against their own group. However, it is unclear whether more specific negative stereotypes are automatically activated among diagnosed individuals and how such automatic stereotyping may be related to self-reported attitudes and emotional reactions. We therefore studied automatically activated reactions toward mental illness among 85 people with schizophrenia, schizoaffective or affective disorders as well as among 50 members of the general public, using a Lexical Decision Task to measure automatic stereotyping. Deliberately endorsed attitudes and emotional reactions were assessed by self-report. Independent of diagnosis, people with mental illness showed less negative automatic stereotyping than did members of the public. Among members of the public, stronger automatic stereotyping was associated with more self-reported shame about a potential mental illness and more anger toward stigmatized individuals. Reduced automatic stereotyping in the diagnosed group suggests that people with mental illness might not entirely internalize societal stigma. Among members of the public, automatic stereotyping predicted negative emotional reactions to people with mental illness. Initiatives to reduce the impact of public stigma and internalized stigma should take automatic stereotyping and related emotional aspects of stigma into account.     

The measurement properties of stigmatizing attitudes towards mental disorders: results from two community surveys

Stigma is a well‐documented concern of people living with mental illness. Through the use of novel exploratory structural equation modelling (ESEM) methods, we aimed to elucidate the structure of stigma as measured by two stigma scales (the Depression Stigma Scale and the Social Distance Scale), to establish dimensions of stigma towards a range of disorders and to compare levels on these dimensions between disorders and respondent subgroups. We used data from two Australian national surveys, one of the general community aged 15+ and another of youths aged 15–25. Stigma responses were elicited using a range of mental illness vignettes: depression, schizophrenia, social phobia and post‐traumatic stress disorder (PTSD). ESEM revealed that the structure of stigmatizing attitudes in young people and adults is comparable in personally held attitudes and those perceived in others. Personal and perceived stigma formed distinct dimensions with each comprising “Weak‐not‐sick” and “Dangerous/unpredictable” components. The social distance dimension of stigma was separate from other components of stigma, supporting the appropriateness of the existing Social Distance Scale. Scales reflecting these dimensions had different patterns of association with respondent age and gender, and the type of mental disorder portrayed in the vignette. Copyright © 2014 John Wiley & Sons, Ltd.     

Involuntary hospitalization,stigma stress and suicidality: a longitudinal study

People with severe mental illness and a history of involuntary hospitalization may experience stigma-related stress and suffer negative consequences as a result. However, the long-term impact of stigma stress on suicidality in this population remains unknown. This longitudinal study therefore examined stigma stress, self-stigma, self-esteem and suicidal ideation among 186 individuals with mental illness and recent involuntary hospitalization. After adjusting for age, gender, diagnoses and symptoms, more stigma stress at baseline predicted suicidal ideation after 2 years, mediated by increased self-stigma and decreased self-esteem after 1 year. Anti-stigma interventions that reduce stigma stress and self-stigma could therefore support suicide prevention.     

Social Distance and Community Attitudes Towards People with Psycho-Social Disabilities in Uttarakhand,India

Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.     

Internalized stigma predicts erosion of morale among psychiatric outpatients

Stigma in society causes harm to people with severe mental illness (SMI) and internalized stigma represents its psychological point of impact. We evaluated the extent of internalized stigma in a sample of outpatients with SMI, using the Internalized Stigma of Mental Illness (ISMI) Scale, developed with consumer input. About a third of the sample reported high levels of internalized stigma. We tested whether internalized stigma predicted increased depressive symptoms and reduced self-esteem at 4-month follow-up, controlling for baseline levels. Depression was predicted by Alienation, Stereotype Endorsement, Social Withdrawal Scales and total ISMI score. Reduced self-esteem was predicted by Alienation. ISMI results were stronger than those for the widely used Devaluation–Discrimination Scale. The finding that alienation further reduces morale speaks to the difficulty of pulling oneself out of this type of vicious cycle without assistance.     

Quality of Life and Self-Stigma in Individuals with Schizophrenia

Recent mental illness stigma research has almost exclusively studied community and family responses to the stigmas of mental illness. Too little has been done to understand the current subjective experience of psychiatric patients. Our study explores the influence of self-stigma on the quality of life of mentally disabled people. Participating in the survey were 100 people diagnosed with schizophrenia. Using Ritsher??s Internalized Stigma of Mental Illness Scale, which incorporates alienation, stereotype endorsement, discrimination experience, social withdrawal, and social resistance subscales, along with the standard SF-12, helped us evaluate the subjective experience of mental illness stigma. According to our survey data, self-stigma correlates negatively with all of the quality of life measures except the Internalized Stigma of Mental Illness subscale??s ??stigma resistance??, which did not correlate significantly. Improved stigma resistance requires an understanding of one??s sociocultural background and a strong social network to provide the sense of comfort and security that enables a fulfilling life.     

Stigma of depression is more severe in Chinese Americans than Caucasian Americans

Stigma of mental illness is a major obstacle to its diagnosis and treatment and may be worse among Asians than Caucasians. This study compared the stigma of depression in 50 Chinese Americans (CA) and 50 Caucasian Americans (WA). Subjects were asked to read 5 case vignettes in the following order: diabetes mellitus (DB), major depressive disorder (MDD), somatoform depression (SD), psychotic depression (PD), and fever of unknown origin (HA). Diagnosis of each case was not revealed. Subjects then rated their response to each case, on a Likert scale from "strongly disagree" to "strongly agree," to 25 statements that contained 6 stigma factors: fear, shame, cognitive distortion, social consensus, discrimination, and sanction. Composite scores constructed from ratings of each factor were used to calculate the severity of stigma. Stigma of all 5 cases was worse in CA than WA. Both groups ranked DB and HA to be least and PD to be most stigmatizing. CA rated SD to be less stigmatizing than MDD but not WA. We concluded that stigma formation and severity were determined by fear, shame, cognitive distortion, social communication, consensus, and sanction. Mental symptoms, particularly psychotic symptoms, were more stigmatizing than physical symptoms, especially for CA. Belief that depression was like a physical illness did not diminish its stigma.     

Psychoanalytic Contributions to the Generation of Creativity in Children

Stigma of mental illness is a major obstacle to its diagnosis and treatment and may be worse among Asians than Caucasians. This study compared the stigma of depression in 50 Chinese Americans (CA) and 50 Caucasian Americans (WA). Subjects were asked to read 5 case vignettes in the following order: diabetes mellitus (DB), major depressive disorder (MDD), somatoform depression (SD), psychotic depression (PD), and fever of unknown origin (HA). Diagnosis of each case was not revealed. Subjects then rated their response to each case, on a Likert scale from “strongly disagree” to “strongly agree,” to 25 statements that contained 6 stigma factors: fear, shame, cognitive distortion, social consensus, discrimination, and sanction. Composite scores constructed from ratings of each factor were used to calculate the severity of stigma. Stigma of all 5 cases was worse in CA than WA. Both groups ranked DB and HA to be least and PD to be most stigmatizing. CA rated SD to be less stigmatizing than MDD but not WA. We concluded that stigma formation and severity were determined by fear, shame, cognitive distortion, social communication, consensus, and sanction. Mental symptoms, particularly psychotic symptoms, were more stigmatizing than physical symptoms, especially for CA. Belief that depression was like a physical illness did not diminish its stigma.     

Testing Social Cognitive Models of Mental Illness Stigma: The Prairie State Stigma Studies

Abstract

Social cognitive models of stigma define the relationship among: signals that suggest a person is mentally ill, stigmatizing attitudes about the person with mental illness, affective reactions to the stigmatizing attitude, and behavior responses to these attitudes and emotions. The Prairie State Stigma Studies were a set of investigations completed over the past five years examining stigma from the perspective of the general public. Several of the studies examined path models that explain the relationship between stigmatizing attitudes and discriminatory behavior. Among the many results was the finding that stigmatizing attitudes about dangerousness were especially problematic, leading to fear and avoidance of persons with mental illness. The studies also examined ways to change stigmatizing attitudes and corresponding behaviors. Results suggested that contact with persons who are challenged by psychiatric disabilities has a broad and positive effect on public stigma. Future directions for research on social cognitive models of stigma are discussed.     

Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders

Research has paradoxically linked awareness of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. To explore this possibility we performed a cluster analysis of 75 persons with schizophrenia spectrum disorders based on single measures of insight using the Positive and Negative Syndrome Scale, internalized stigma using the Internalized Stigma of Mental Illness Scale, and compared groups on concurrent assessments of hope and self-esteem. Three groups were produced by the cluster analyses: low in sight/mild stigma (n = 23), high insight/minimal stigma (n = 25), and high insight/moderate stigma (n = 27). As predicted, analysis of variance-comparing groups revealed that the high insight/moderate stigma group had significantly the lowest levels of hope on the Beck Hopelessness Scale and self-esteem using the Multidimensional Self-esteem Inventory. As predicted, the high insight/minimal stigma group also had significantly less impaired social function than the other groups. Implications for assisting persons to come to cope with awareness of illness and stigma are discussed.     

Automatically activated shame reactions and perceived legitimacy of discrimination: A longitudinal study among people with mental illness

Perceived legitimacy of discrimination shapes reactions to mental illness stigma among stigmatized individuals. We assessed deliberately endorsed versus automatic shame-related reactions to mental illness as predictors of change in perceived legitimacy of discrimination over six months among 75 people with mental illness. Automatically activated shame-related associations with mental illness were measured using the Brief Implicit Association Test, deliberately endorsed beliefs via self-report. Controlling for depression and perceived stigma, stronger baseline automatic shame-related associations, but not deliberately endorsed beliefs, predicted higher perceived legitimacy of discrimination after six months. Automatically activated shame reactions may increase vulnerability to mental illness stigma.     

Stigma as a barrier to recovery: The consequences of stigma for the self-esteem of people with mental illnesses.

OBJECTIVE: The objective of this study was to determine whether stigma affects the self-esteem of persons who have serious mental illnesses or whether stigma has few, if any, effects on self-esteem. METHODS: Self-esteem and two aspects of stigma, namely, perceptions of devaluation-discrimination and social withdrawal because of perceived rejection, were assessed among 70 members of a clubhouse program for people with mental illness at baseline and at follow-up six and 24 months later. RESULTS: The two measures of perceptions of stigma strongly predicted self-esteem at follow-up when baseline self-esteem, depressive symptoms, demographic characteristics, and diagnosis were controlled for. Participants whose scores on the measures of stigma were at the 90th percentile were seven to nine times as likely as those with scores at the 10th percentile to have low self-esteem at follow-up. CONCLUSIONS: The stigma associated with mental illness harms the self-esteem of many people who have serious mental illnesses. An important consequence of reducing stigma would be to improve the self-esteem of people who have mental illnesses.     

Stigma in the lives of adolescents with epilepsy: a review of the literature

The World Health Organization, the Centers for Disease Control and Prevention, and the Epilepsy Foundation have recently focused attention on problems experienced by people with epilepsy as a result of stigma. Stigma is associated with poor psychosocial health outcomes in people with epilepsy, and its effects may be strongly felt by adolescents who are already dealing with the challenges of developing self-identity and self-esteem. This review synthesizes the empirical literature on stigma in the lives of adolescents with epilepsy. Beginning research indicates that stigma is related to quality of life in adolescents with epilepsy, although existing measures may not yet fully capture how this stigma is experienced. For example, instead of reporting stigma actually experienced, adolescents report limiting disclosure of their illness, perhaps because they anticipate being stigmatized in a peer social environment that fosters misconceptions about people with epilepsy. Recommendations for future research are discussed.     

Decreasing the Stigma of Mental Illness Through a Student-Nurse Mentoring Program: A Qualitative Study

Stigma is defined as endorsing prejudicial attitudes about mental illness leading to discriminatory behaviors. It undermines the quality of medical care received by people with mental illness. Research suggests contact based interventions are effective in reducing stigma and increasing positive attitudes towards people with mental illness. This paper describes the development of a consumer led student-nurse mentoring program as part of nursing student education. People with lived mental health experience would mentor student nurses regarding the harmful effects of stigma and the beneficial outcomes of affirming attitudes. Seventy members of stakeholder groups (people with lived mental health experience and student nurses) participated in focus groups. Qualitative analyses revealed themes across stakeholder groups regarding: perceived mental health stigma from nurses, ways to reduce stigma, target message for the mentorship program, characteristics of mentors and logistics in developing such a program within the student nurse curricula.     

Demonstrating Translational Research for Mental Health Services: An Example from Stigma Research

In seeking to understand how the goal of providing efficient and effective mental health services can best be attained, services researchers have developed principles and methods that distinguish it from other research approaches. In 2000, the National Institute of Mental Health called for translational research paradigms that seek to expand the conceptual and methodological base of mental health services with knowledge gained from basic behavioral sciences such as cognitive, developmental, and social psychology. The goal of this paper is to enter the discussion of what is translational research by illustrating a services research program of the Chicago Consortium for Stigma Research on mental illness stigma. Our research strives to explain the prejudice and discrimination that some landlords and employers show toward people with mental illness in terms of basic research from social psychology and contextual sociology. We end the paper with a discussion of the implications of this research approach for the very practical issues of trying to change mental illness stigma.     

Subjective social status moderates cortisol responses to social threat

Research has demonstrated a robust relationship between social status, physiology and health in humans and animals. However, perceptions of social status within a specific social group have rarely been studied in this area and may provide additional relevant information. The current investigation examines subjective perceptions of social status as a moderator of cognitive, emotional and cortisol responses to stressor tasks characterized by social-evaluative threat or its absence. As part of a larger study, 81 college students living in a residential dormitory completed a measure of their subjective perceptions of their social status within their dormitory floor. They were randomly assigned to undergo a standard performance stressor task either with or without social evaluation. It was hypothesized that individuals who perceived that they were of low status within their dorm group would show greater increases in negative self-evaluative emotions (i.e., shame) and cognitions (low social self-esteem) and greater cortisol responses to the stressor under conditions of social-evaluative threat. Subjective social status moderated cortisol responses to the social-evaluative stressor, but in a direction opposite that hypothesized. Individuals who perceived themselves to be of high status showed sizable and significant cortisol increases (both peak and recovery), while those who perceived themselves to be of low status did not mount a significant cortisol response to the stressor. Both groups showed increased negative self-evaluative responses to the tasks. A discussion of the possible health implications of the robust cortisol responses of high status individuals and the hyporesponsive cortisol reactions of low status individuals is provided.