Internalized stigma in schizophrenia: Relations with dysfunctional attitudes,symptoms, and quality of life

Internalized stigma refers to the process by which individuals with mental illness apply negative stereotypes to themselves, expect to be rejected by others, and feel alienated from society. Though internalized stigma has been hypothesized to be associated with maladaptive cognitions and expectations of failure, this relationship with dysfunctional attitudes has not been fully examined. In the present study, 49 individuals with schizophrenia or schizoaffective disorder completed the Internalized Stigma of Mental Illness Scale (ISMI; Ritsher et al., 2003) in addition to measures tapping defeatist performance beliefs, beliefs regarding low likelihood of success and limited resources, negative symptoms, depression, and quality of life. Consistent with prior research, internalized stigma was correlated with depression and quality of life but not with negative symptoms. Further, internalized stigma was correlated with both measures of dysfunctional attitudes. After controlling for depressive symptomatology, the relationship between internalized stigma and beliefs regarding low likelihood of success and limited resources remained significant, and though the correlation between defeatist performance beliefs and internalized stigma was no longer significant, it was of a similar magnitude. Overall, these data suggest that dysfunctional attitudes play a role in internalized stigma in individuals with schizophrenia, indicating a possible point of intervention.     

Study of understanding the internalized stigma of schizophrenia in psychiatric nurses in Japan

Aim: ‘Internalized stigma’ is a construct that reflects the degree to which a person accepts beliefs endorsed by society about mental illness. Among people with schizophrenia spectrum disorders, internalized stigma has been found to moderate the associations between insight and social function, hope, and self‐esteem. Among families of patients with schizophrenia, internalized stigma may not only hinder help‐seeking but also result in the families attempting to provide care themselves, without assistance from mental health services. Little is known about internalized stigma among service providers, especially psychiatric nurses in Japan. Therefore, we investigated the correlation between internalized stigma and ‘beliefs about the most appropriate form of hospitalization’ among psychiatric nurses. Methods: The subjects were 215 psychiatric nurses employed in psychiatric hospitals who completed the personal stigma scale, perceived stigma scales, and Difficulty of Community Living Scale (DCLS) with respect to a chronic schizophrenia case vignette. Results: Internalized stigma was positively correlated with greater ‘beliefs about the most appropriate form of hospitalization’ among psychiatric nurses. We also showed that stronger ‘beliefs about the social disadvantages of schizophrenia patients in the community’ was positively correlated with stronger ‘beliefs about the most appropriate form of hospitalization’. Conclusion: The present findings suggest that the psychiatric nurses employed at Japanese psychiatric hospitals have a pessimistic view of the community living of people with schizophrenia and their families. And these psychiatric nurses' beliefs were related to their understanding of the deeply dependent relationship between patients and families, and was related to the Confucian ideal.     

An integrative model of internalized stigma and recovery-related outcomes among people diagnosed with schizophrenia in rural China

Purpose

Internalized stigma, an adverse psychological process, severely impedes the lives of people diagnosed with schizophrenia and restricts them from social integration and recovery. The aim of this study was to empirically evaluate an integrative model of relationship between internalized stigma and patients’ recovery-related outcomes among people diagnosed with schizophrenia in a rural Chinese community.

Method

A total of 232 people diagnosed with schizophrenia in Xinjin, Chengdu, participated in this study and completed measures of internalized stigma, social interaction, perceived social support, social functioning, and symptoms. The internalized stigma of mental illness scale (ISMI) was used to measure the internalized stigma. Path analysis was used to test the association between internalized stigma and recovery-related outcomes.

Results

There were no significant differences in mean scores of ISMI by gender, age (18–64 years and ≥ 65 years), education, marital status, or economic capacity. Internalized stigma was negatively associated with perceived social support and social interaction. Furthermore, higher level of internalized stigma was associated with impaired social functioning, and a lower level of social functioning was significantly associated with more severe symptoms.

Conclusion

Internalized stigma is associated with poor social interaction and weakened perceived social support in people diagnosed with schizophrenia, and is linked negatively to outcomes in their recovery. It is essential to tailor interventions related to reducing internalized stigma within a Chinese context and evaluate the effectiveness of anti-stigma intervention on recovery for people diagnosed with schizophrenia.

     

Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months

Research suggests stigma is a barrier to self-esteem and the attainment of resources in schizophrenia. Less clear is the association of stigma experiences with symptoms and social function both concurrently and prospectively. To assess this, symptoms were measured using the Positive and Negative Syndrome Scale, social function was measured using the Quality of Life Scale and stigma experience was assessed using the Internalized Stigma of Mental Illness Scale among 36 persons with schizophrenia at two points, 6 months apart. Correlations found stigma was associated with concurrent levels of positive and emotional discomfort symptoms and degree of social contact. When initial stigma levels were controlled for, stigma at 6 months was predicted by baseline levels of positive symptoms. Greater initial stigma predicted greater emotional discomfort at follow-up. Results suggest internalized stigma is linked with social function and symptoms. Positive symptoms may make some persons with schizophrenia more vulnerable to ongoing stigma experience.     

The relationship of trait to state motivation: the role of self-competency beliefs

Even when people with schizophrenia describe themselves as generally motivated and eager to engage in activities, they may not actually be motivated in the present moment. In order to better understand the relationship between trait and state motivation, we aimed to assess trait motivation and state intrinsic motivation, and investigate their relations to each other and to criterion-related variables including cognition, negative symptoms, and beliefs about one's own competency-also known as perceived competency (PC). Further, we investigated whether PC mediates the relationships between state intrinsic motivation (IM) and trait motivation dimensions. Forty individuals with schizophrenia or schizoaffective disorders were administered two self-report measures of motivation, the Motivational Trait Questionnaire (Kanfer, R., Ackerman, P., 2000. Individual differences in work motivation: further explorations of a trait framework. Appl. Psychol. 49 (3), 470-482) and the Intrinsic Motivation Inventory for Schizophrenia Research (Choi, J., Medalia, A., 2010. Intrinsic motivation and learning in a schizophrenia spectrum sample. Schizophr. Res. 118, 12-19), as well as measures of PC, cognition and symptoms. The results showed that in people with schizophrenia, trait approach motivation, but not trait avoidance motivation, is positively correlated with state intrinsic motivation and PC. There was evidence that PC partially mediates the relationship between trait approach motivation and state intrinsic motivation to do the task. These results support the role of therapies that directly address self-competency beliefs and set the groundwork for future investigations on the impact of such treatments on motivation.     

Stereotype endorsement,metacognitive capacity,and self-esteem as predictors of stigma resistance in persons with schizophrenia

Objective

While research continues to document the impact of internalized stigma among persons with schizophrenia, little is known about the factors which promote stigma resistance or the ability to recognize and reject stigma. This study aimed to replicate previous findings linking stigma resistance with lesser levels of depression and higher levels of self-esteem while also examining the extent to which other factors, including metacognitive capacity and positive and negative symptoms, are linked to the ability to resist stigma.

Method

Participants were 62 adults with schizophrenia-spectrum disorders who completed self-reports of stigma resistance, internalized stigma, self-esteem, and rater assessments of positive, negative, disorganization, and emotional discomfort symptoms, and metacognitive capacity.

Results

Stigma resistance was significantly correlated with lower levels of acceptance of stereotypes of mental illness, negative symptoms, and higher levels of metacognitive capacity, and self-esteem. A stepwise multiple regression revealed that acceptance of stereotypes of mental illness, metacognitive capacity, and self-esteem all uniquely contributed to greater levels of stigma resistance, accounting for 39% of the variance.

Conclusion

Stigma resistance is related to, but not synonymous with, internalized stigma. Greater metacognitive capacity, better self-esteem, and fewer negative symptoms may be factors which facilitate stigma resistance.     

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.     

Preliminary structure and predictive value of attenuated negative symptoms in 22q11.2 deletion syndrome

Current research in schizophrenia suggests that negative symptoms cannot be considered a unitary construct and should be divided in two dimensions: lack of motivation and impoverishment of expression. In addition, negative symptoms are particularly related to decreased daily-life functioning. In the present study, we aimed to replicate these results in a sample of participants with 22q11.2 deletion syndrome (22q11DS), a neurogenetic condition associated with high risk of developing schizophrenia. We also expected to observe an association between the COMT Val/Met polymorphism and negative symptoms. We examined the factorial structure of negative symptoms in a sample of 47 individuals with 22q11DS using the Structured Interview for Prodromal Symptoms (SIPS) and the Positive and Negative Syndrome Scale (PANSS). We also performed stepwise regression analyses to investigate the associations between negative symptoms, adaptive skills and the COMT Val/Met polymorphism. Negative symptoms were explained by a two-factor solution, namely the "amotivation and social withdrawal" and the "emotional withdrawal and expression" dimensions. The motivational dimension was significantly associated with daily-life functioning. Met carriers were rated as experiencing significantly more symptoms of amotivation. The results are interpreted in the light of existing cognitive models in the field of motivation and schizophrenia.     

Interpersonal factors contributing to the stigma of schizophrenia: social skills, perceived attractiveness, and symptoms

This study investigated the interpersonal factors (i.e., social skills, symptoms, perceived physical attractiveness) which are related to the stigma of schizophrenia. Social skills performance was assessed for 39 individuals with schizophrenia who participated in two role-plays with a confederate. Social skills ratings comprised 'overall social skill', 'meshing', 'clarity', and 'fluency' of speech, 'gaze', 'pleasantness' of conversation, 'involvement' in conversation, 'number of questions asked' during conversation, and 'perceived strangeness'. Symptomatology was assessed with the Brief Psychiatric Rating Scale. Ratings of perceived physical attractiveness were obtained by pausing the videotaped role-plays after the first 2s of the interaction. Ratings of 'social distance', based on an independent sample who observed the role-plays, were used as a proxy measure of stigma. The results showed that social distance was best statistically predicted by perceived strangeness, which in turn, was best statistically predicted by ratings of overall social skill. Negative symptoms appeared to have a more robust association with desired social distance than positive symptoms. Interpersonal factors, such as overall social skill, negative symptoms, and perceived strangeness, may contribute to stigma.     

精神分裂症患者自知力与内在耻感的相关性研究(英文)

背景精神分裂症患者自知力和内在耻感的关系具有理论和实践上的重要性,因为这和患者寻找或接受治疗的意愿密切相关。目的研究中国大陆精神分裂症患者自知力和内在耻感的关系。方法共有65例住院治疗的精神分裂症患者和27例门诊治疗的精神分裂症患者(病程的中位数为4年)完成了两个中文版自评量表-精神疾病内在耻感量表(Internalized Stigma of Mental Illness,ISMI)和修订版病耻感经历问卷(Modified Consumer Experiences of Stigma Questionnaire,MCESQ)的测评。由高年资精神科医生采用阳性症状量表(Scale for Assessment of Positive Symptoms,SAPS)和阴性症状量表(Scale for Assessment of Negative Symptoms,SANS)评定了患者的精神病理症状。由两位高年资精神科医生采用简明精神病学量表中文版的自知力条目评定患者对自身精神疾病的认知,依据分数将患者分为有自知力组和无自知力组。结果有自知力组有49例患者,无自知力组为43例。无自知力患者的病程显著短于有自知力组,更可能为住院治疗者,并且具有更明显的阴性和阳性症状(仅仅表现在趋势上)。有自知力组患者在精神疾病内在耻感量表疏离分量表得分上显著高于无自知力组的患者,但是两个量表的其他分量表得分组间无统计学差异。两个量表48个条目中仅有4个条目得分存在组间差异。Logistic回归没有发现无自知力和两个耻感量表分数或症状量表得分之间存在相关性。结论在中国大陆精神分裂症门诊与住院患者中进行的本研究不支持以前的研究发现:即有自知力的精神分裂症患者会报告更多的耻感经历。本研究使用的耻感量表在中国地区的应用还需要进一步的修订和证实;未来需要对下列问题进行研究:选择不同诊断的患者、对自知力进行更精细的评估以及随时间推移自知力及病耻感经历的波动等等,进一步澄清精神分裂症患者中这两个现象间的复杂关系。     

A stress-coping model of mental illness stigma: II. Emotional stress responses, coping behavior and outcome

Stigma can be a major stressor for people with schizophrenia and other mental illnesses, leading to emotional stress reactions and cognitive coping responses. Stigma is appraised as a stressor if perceived stigma-related harm exceeds an individual's perceived coping resources. It is unclear, however, how people with mental illness react to stigma stress and how that affects outcomes such as self-esteem, hopelessness and social performance. The cognitive appraisal of stigma stress as well as emotional stress reactions (social anxiety, shame) and cognitive coping responses were assessed by self-report among 85 people with schizophrenia, schizoaffective or affective disorders. In addition to self-directed outcomes (self-esteem, hopelessness), social interaction with majority outgroup members was assessed by a standardized role-play test and a seating distance measure. High stigma stress was associated with increased social anxiety and shame, but not with cognitive coping responses. Social anxiety and shame predicted lower self-esteem and more hopelessness, but not social performance or seating distance. Hopelessness was associated with the coping mechanisms of devaluing work/education and of blaming discrimination for failures. The coping mechanism of ingroup comparisons predicted poorer social performance and increased seating distance. The cognitive appraisal of stigma-related stress, emotional stress reactions and coping responses may add to our understanding of how stigma affects people with mental illness. Trade-offs between different stress reactions can explain why stress reactions predicted largely negative outcomes. Emotional stress reactions and dysfunctional coping could be useful targets for interventions aiming to reduce the negative impact of stigma on people with mental illness.     

Intrinsic motivation as a predictor of work outcome after vocational rehabilitation in schizophrenia

Intrinsic motivation is a construct commonly used in explaining goal-directed behavior. In people with schizophrenia, intrinsic motivation is usually subsumed as a feature of negative symptoms or underlying neurocognitive dysfunction. A growing literature reflects an interest in defining and measuring motivational impairment in schizophrenia and in delineating the specific role of intrinsic motivation as both an independent predictor and a mediator of psychosocial functioning. This cross-sectional study examined intrinsic motivation as a predictor of vocational outcomes for 145 individuals with schizophrenia and schizoaffective disorder participating in a 6-month work rehabilitation trial. Correlation and mediation analyses examined baseline intrinsic motivation and negative symptoms in relation to work hours and work performance. Data support a significant relationship between intrinsic motivation and negative symptoms and significant correlations with outcome variables, such that lower negative symptoms and greater intrinsic motivation were associated with better work functioning. Moreover, in this sample, intrinsic motivation fully mediated the relationships between negative symptoms, work productivity, and work performance. These results have significant implications on the design of work rehabilitation interventions for people with schizophrenia and support a role for targeting intrinsic motivation directly to influence vocational functioning. Future directions for research and intervention are discussed.     

Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia

Poor social and vocational outcomes have long been observed in schizophrenia. Two of the most consistent predictors are negative symptoms and cognitive impairment. We investigate the hypothesis that cognitive content--defeatist beliefs regarding performance--provides a link between cognitive impairment, negative symptoms, and poor functioning in schizophrenia. A total of 77 individuals (55 patients diagnosed with schizophrenia or schizoaffective disorder and 22 healthy controls) participated in a cross-sectional study of psychopathology. Tests of memory, abstraction, attention, and processing speed, as well as current psychopathology, functioning, and endorsement of defeatist beliefs, were employed. Greater neurocognitive impairment was associated with elevated defeatist belief endorsement, higher negative symptom levels, and worse social and vocational functioning. Notably, statistical modeling indicated that defeatist belief endorsements were mediators in the relationship between cognitive impairment and both negative symptoms and functioning. These effects were independent of depression and positive symptom levels. The results add to the emerging biopsychosocial understanding of negative symptoms and introduce defeatist beliefs as a new psychotherapeutic target.     

The positive-negative distinction in schizophrenia. Review of natural history validators.

A review of the interaction between the positive-negative symptom distinction in schizophrenia and multiple measures of illness natural history reveals some redundant and compelling patterns. Negative or deficit symptoms are often associated with inferior social/instrumental functioning premorbidly, more abnormal voluntary/involuntary movements at illness presentation, and poorer long-term outcome when present beyond the early phase of illness. Negative symptoms are semi-independent of positive symptoms. They are variable early in the illness but accrue in severity, stability, and prognostic weight with time. The nature of the processes that generate negative symptoms and their specificity to schizophrenia remain to be elucidated. Nevertheless, it is clear that negative symptoms are a common and valid component of schizophrenia and deserve recognition as such in our nosology.     

Familial liability to schizophrenia: a sibling study of negative symptoms

Negative symptoms are important features in schizophrenia, so in milder form they might also serve as indicators of "unexpressed" liability to schizophrenia among patients' adult relatives without schizophrenia. To address this question, we assessed negative symptoms in 39 stable schizophrenia or schizoaffective outpatients, 39 of their siblings, 38 well control probands, and 38 of their siblings. Negative symptom measures included standard behavior ratings of the core negative symptoms of affective flattening and alogia, as well as a self-report measure of social anhedonia. As expected, even stable outpatients with schizophrenia exhibited significantly more negative symptoms than control probands and control siblings. However, negative behavioral symptoms of affective flattening, alogia, and anhedonia did not significantly differentiate the siblings of the schizophrenia patients from the control probands or their siblings, although there were some trends for anhedonia. The findings suggest that core negative symptoms of observed affective flattening and poverty of speech are not likely to be useful as strong indicators of "unexpressed" liability to schizophrenia.     

Association of stigma resistance with emotion regulation — Functional magnetic resonance imaging and neuropsychological findings

Backgroud

Personal characteristics contribute to whether negative attitudes in society are internalized as deteriorating self-stigma. Studies in healthy subjects suggest that resilience is associated with the regulation of amygdala activation by the medial prefrontal cortex (mPFC), but little is known about the factors that contribute to individual stigma resistance in psychiatric patients.

Methods

We assessed stigma (by measuring association strengths between social inferiority and schizophrenia by an implicit association test) in 20 patients with schizophrenia and in 16 age- and sex-matched healthy control subjects. The brain activation strengths were measured by functional magnetic resonance imaging during evaluation of schizophrenia-related statements and of control statements.

Results

Association strengths between social inferiority and schizophrenia were inversely related to the strength of the activation of the rostro-ventral mPFC. This inverse correlation survived adjustment for global functioning, depression symptom scores, and insight. Activation of the rostro-ventral mPFC was negatively correlated with activation of the amygdala. The association strengths between social inferiority and schizophrenia correlated with the compromised performance in a Stroop task, which is a measure of cognitive regulation.

Discussion

Our findings suggest that individual stigma resistance is associated with emotion regulation. These findings may help to understand better stigma resistance and thereby aid the development of patient interventions that add to the public anti-stigma work in reducing devastating effects of stigma.     

Examining the latent structure of negative symptoms: is there a distinct subtype of negative symptom schizophrenia?

Negative symptoms have emerged as a replicable factor of symptomatology within schizophrenia. Although rating scales provide assessments along dimensions of severity, categorization into a negative symptom subtype is typically conducted. A categorical view of negative symptoms is best reflected in the proposal that enduring, primary negative symptoms, or deficit symptoms, reflect a distinct subtype of schizophrenia . Despite an accumulation of findings that support a categorical conceptualization, the data are also consistent with a dimensional-only model where negative symptom subtypologies simply reflect an extreme on a continuum of severity. Using taxometric statistical methods , the present study examined whether a taxonic, or latent class, model best describes negative symptoms in a sample of 238 schizophrenia patients. In order to obtain more stable estimates of symptoms, ratings on the Scale for the Assessment of Negative Symptoms [Andreasen, N.C., 1982. Negative symptoms in schizophrenia: Definition and reliability. Arch. Gen. Psychiatry 39, 784-788.] were averaged across two assessments over a 6-month period. Two taxometric methods, maximum covariance analysis (MAXCOV) and mean above minus below a cut (MAMBAC) identified a latent class or taxon with a base rate of approximately 28-36%. Members of the negative symptom taxon differed from the nontaxon class in that taxon members were more likely to be male and demonstrated poorer social functioning. Taxon and nontaxon schizophrenia patients did not differ in psychotic or affective symptoms. The findings converge to provide support for a categorical view of negative symptoms. Further research is required to replicate the present taxonic findings and to examine characteristics (including possible etiological factors) associated with this negative symptom taxon.     

Amotivation in Schizophrenia: Integrated Assessment With Behavioral,Clinical, and Imaging Measures

Motivational deficits play a central role in disability caused by schizophrenia and constitute a major unmet therapeutic need. Negative symptoms have previously been linked to hypofunction in ventral striatum (VS), a core component of brain motivation circuitry. However, it remains unclear to what extent this relationship holds for specific negative symptoms such as amotivation, and this question has not been addressed with integrated behavioral, clinical, and imaging measures. Here, 41 individuals with schizophrenia and 37 controls performed a brief, computerized progressive ratio task (PRT) that quantifies effort exerted in pursuit of monetary reward. Clinical amotivation was assessed using the recently validated Clinical Assessment Interview for Negative Symptoms (CAINS). VS function was probed during functional magnetic resonance imaging using a monetary guessing paradigm. We found that individuals with schizophrenia had diminished motivation as measured by the PRT, which significantly and selectively related to clinical amotivation as measured by the CAINS. Critically, lower PRT motivation in schizophrenia was also dimensionally related to VS hypofunction. Our results demonstrate robust dimensional associations between behavioral amotivation, clinical amotivation, and VS hypofunction in schizophrenia. Integrating behavioral measures such as the PRT will facilitate translational efforts to identify biomarkers of amotivation and to assess response to novel therapeutic interventions.Key words: motivation, progressive ratio, ventral striatum, fMRI, negative symptoms     

The Brief Negative Symptom Scale: Validation in a multicenter Brazilian study

BackgroundNegative symptoms are a core feature of schizophrenia. The Brief Negative Symptom Scale (BNSS) is a scale developed to measure negative symptoms in schizophrenia.MethodsThe present study aimed to examine the construct validity of BNSS, by using convergent and divergent validities as well as factor analysis, in a Brazilian sample of 111 outpatients diagnosed with schizophrenia by DSM-5. Patients were evaluated by the Brazilian version of the BNSS and positive and negative subscales of the Positive and Negative Syndrome Scale (PANSS).ResultsAssessment of patients by both instruments revealed an excellent internal consistency (Cronbach's alpha = 0.938) or inter-rater reliability (ICC = 0.92), as well as a strong correlation between BNSS and Marder negative PANSS (r = 0.866) and a weak correlation of the instrument with the positive PANSS (r = 0.292), thus characterizing convergent and discriminant validities, respectively. The exploratory factor analysis identified two distinct factors, namely, motivation/pleasure and emotional expressivity, accounting for 68.63% of the total variance.ConclusionThe study shows that the Brazilian version of the BNSS has adequate psychometric properties and is a reliable instrument for the assessment of negative symptoms in schizophrenia, either for clinical practice or research.