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

doi:10.1016/j.psychres.2014.05.009

Psychiatry Research

Volume 219, Issue 1, 30 September 2014, Pages 92-94

https://doi.org/10.1016/j.psychres.2014.05.009 Get rights and content

Abstract

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.

Introduction

Previous studies have found high levels of internalized stigma (or self-stigma) among patients with schizophrenia, and these subjective experiences have been linked with numerous negative outcomes, such as low self-worth, social isolation, increased symptom severity, and poorer treatment adherence (see Gerlinger et al., 2013). Further, internalized stigma is often associated with depressive symptoms (Park et al., 2013) and hopelessness (Yanos et al., 2008) among schizophrenia patients, even in prospective research (Lysaker et al., 2007, Corrigan et al., 2011). However, the literature is somewhat mixed as several studies have not confirmed these associations (see Gerlinger et al., 2013).

Despite these relatively robust associations, little is known about potential factors that contribute to the development and intensity of internalized stigma, and processes that lie behind its relationship with depression and hopelessness. Indeed, a recent meta-analysis has called for more studies investigating moderator variables, such as personality traits, of the complex association between stigma and various relevant outcomes (Livingston and Boyd, 2010).

The relevance of personality traits with regard to various psychopathological outcomes in patients with schizophrenia has been receiving increased attention. The psychobiological model of personality developed by Cloninger et al. (1993) might be especially relevant as temperament dimensions are conceptually linked with different genetic and neurobiological underpinnings. The temperament dimension Harm avoidance (HA), defined as sensitivity to aversive stimuli that evoke negative emotions such as anticipatory worry and fear (Cloninger et al., 1993), is known to be elevated and associated with depressive symptoms in schizophrenia patients (Aukst Margetić et al., 2009). It should be noted, however, that HA is increased and related to depression in various psychiatric populations, while the combination of high HA with low Reward Dependence may be a more specific characteristic of schizophrenia (Miettunen and Raevuori, 2012). Moreover, it was previously shown that HA serves as a unique predictor of internalized stigma in this population (Aukst Margetić et al., 2010). Having in mind the need for identifying conditions and patients׳ characteristics that can intensify the negative consequences of stigma (Livingston and Boyd, 2010), it might be prudent to examine whether HA potentiates depressive symptoms among patients experiencing internalized stigma (i.e., acts as a moderating factor). To our knowledge, no previous study has examined personality as a potential moderator of this relationship.

Based on the abovementioned findings, we hypothesized that internalized stigma would be positively associated with depressive symptoms. We also expected temperament dimension HA to be a significant moderator of the stigma–depression relationship, such that experienced stigma would be associated with depressive symptoms to a larger extent in patients who also exhibited higher levels of HA.

Section snippets

Participants

A sample of 117 Caucasian outpatients (68 male), with a diagnosis of schizophrenia established through the Mini International Neuropsychiatric Interview (Lecrubier et al., 1997), were recruited throughout the course of a year at two psychiatric institutions. The mean age of the patients was 34.1 years, S.D. 10.51 (range 19–64), while the mean duration of illness was 7.2 years, S.D. 6.90 (range 0.3–30). The patients were clinically stable for a minimum of three months and all were at least once

Results

The total mean score of internalized stigma was 62.2 (S.D. 12.88), while the mean depression score was 10.7 (S.D. 9.73). Finally, the mean HA score was 19.1 (S.D. 7.04). Internalized stigma was highly positively correlated with depressive symptoms (r=0.57, P<0.001) and moderately with HA (r=0.47, P<0.001). There was also a large positive correlation between HA and depressive symptoms (r=0.60, P<0.001).

The results of the hierarchical multiple regression analysis are presented in Table 1. After

Discussion

As hypothesized, we observed a strong positive association between internalized stigma and depressive symptoms in schizophrenia outpatients. This is in accordance with some of the previous research (Lysaker et al., 2007, Park et al., 2013), although a recent meta-analysis (Gerlinger et al., 2013) indicated mixed results concerning this association. However, we believe some of these inconsistencies are due to certain measurement issues. For example, the lack of a significant correlation between

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The clinical and psychosocial correlates of self-stigma among people with schizophrenia spectrum disorders across cultures: A systematic review and meta-analysis
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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.
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.
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 < .001), a moderate, negative correlation with functioning (r = −0.39, p < .001), and a positive, small correlation with severity of psychotic symptoms (r = 0.29, p < .001), negative symptoms (r = 0.18, p < .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 < .001) and self-esteem (r = −0.55, p < .001). The correlates of self-stigma were similar across cultures.
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.
Mediation of the stigma in the influence of negative symptomatology over recovery in psychosis
2021, International Journal of Clinical and Health Psychology
Background/Objective: The interest in recovery processes in psychotic disorders has boosted the necessity of knowledge about the factors that could influence in such recovery. Negative symptomatology and the stigma have been negatively linked to the recovery process in psychosis. The aim of this investigation is to improve the understanding of how the recovery process is affected by negative symptomatology based on the analysis of the mediating effects of the internalized stigma. Method: The sample was composed of 114 people that had experienced, at some point in their life, at least one clinically relevant psychotic episode. CAPE-42, STORI and ISMI were used for the evaluation. The macro PROCESS for SPSS was used. The indirect effect was calculated using 10.000 samples of bootstrap for the bootstrap confidence intervals (IC) corrected for bias. Results: The results show that the influence of negative symptomatology predicts the stigmatization of the person regarding his disorder. This predicts a negative influence in the recovery process of the psychosis. Conclusions: These results back the importance of adding the reduction of the stigma as a specific strategy to improve the recovery process in psychotic disorders.
Antecedentes/Objetivo: El interés por los procesos de recuperación en los trastornos psicóticos ha impulsado la necesidad de conocer los factores que podrían influir en dicha recuperación. La sintomatología negativa y el estigma se han relacionado negativamente con el proceso de recuperación de la psicosis. El objetivo de esta investigación es mejorar la comprensión sobre cómo el proceso de recuperación se ve afectado por la sintomatología negativa a partir del análisis de los efectos mediadores del estigma internalizado. Método: La muestra estuvo compuesta por 114 personas que habían experimentado, en algún momento de su vida, al menos un episodio psicótico clínicamente relevante. Para la evaluación se usaron el CAPE-42, STORI and e ISMI. Se utilizó el macro PROCESS para SPSS. El efecto indirecto se calculó utilizando 10.000 muestras de bootstrap para los intervalos de confianza (IC) de bootstrap corregidos por sesgo. Resultados: Los resultados muestran que la influencia de la sintomatología negativa predice la estigmatización de la persona con respecto a su trastorno, y esto predice una influencia negativa en el proceso de recuperación de la psicosis. Conclusiones: Estos resultados respaldan la importancia de sumar la reducción del estigma como estrategia específica para mejorar el proceso de recuperación en los trastornos psicóticos.
The impact of illness identity on recovery from severe mental illness: A review of the evidence
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The “Illness Identity” model proposed that self-stigma impacts hope and self-esteem and subsequently leads to a cascade of negative effects on outcomes related to recovery among people diagnosed with severe mental illnesses. The purpose of the present review is to take stock of research support for the model. The citation index SCOPUS was reviewed for all papers published in peer-reviewed journals in English between 2010 and 2019 citing one of the initial 3 articles discussing the model: 111 studies met inclusion criteria and were reviewed. The most frequently tested, and supported, aspects of the model were relationships between self-stigma and self-esteem, hope, psychiatric symptoms and social relationships. Least frequently studied areas were relationships with suicide, avoidant coping, treatment adherence and vocational functioning, although they were supported in the majority of studies. The “insight paradox” was also tested in a relatively small number of studies, with mixed results. Findings were robust to geographic location of study, method, and subpopulation studied. Findings indicate that a large body of research has tested, and largely supported, the various components of the Illness Identity model, although some components need further investigation and there is a need for more comprehensive tests of the model.
The relationship between self-stigma and depression among people with schizophrenia-spectrum disorders: A longitudinal study.
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Citation Excerpt :
Many studies have found that people who internalize the stereotypes associated with their illness were more depressed (Ritsher et al., 2003) (Aukst-Margetic et al., 2014; Belvederi Murri et al., 2016; Bouvet and Bouchoux, 2015; Gerlinger et al., 2013; Kao et al., 2016; Park, 2015; Park et al., 2013; Ritsher and Phelan, 2004a; Rossi et al., 2017; Schrank et al., 2014; Sibitz et al., 2011; Vauth et al., 2007; Yanos et al., 2008). Although, according to a systematic review of the literature, the results concerning this association remain conflicting, it is quite clear that self-stigma can predict nearly a third of the variance of depression (Aukst-Margetic et al., 2014). Longitudinal research has also shown that self-stigma was significantly associated with an increase in depressive symptoms over time (Boyd et al., 2016a; Ritsher and Phelan, 2004a).
Harmful consequences of self-stigma in schizophrenia are well established in the literature, but its relationship with symptomatology remains unclear. Self-stigma describes the process by which some patients eventually accept, adhere to and apply to themselves the stereotypes associated with schizophrenia. This study aims to describe self-stigma experienced by people with schizophrenia in French-speaking Switzerland and to examine the relationship between self-stigma and depression. This was a longitudinal study including 80 participants. Correlation and regression analyses were used to examine the relationship between self-stigma and depression over three points of time. Correlations between Stigma Scale subdimensions and sociodemographic variables indicated that age and duration of illness were associated with the discrimination subscale. Self-stigma was strongly correlated with depression over time, whereby higher scores of self-stigma were associated with higher depression. More precisely, the more the patient felt discriminated against and the less he or she perceived the positive aspects of his or her illness, the greater the symptoms of depression. This study highlights the severity of self-stigma endorsed by people with schizophrenia in French-speaking Switzerland. The results provide new knowledge about self-stigma and its potential impact on depressive symptoms. Implementation of self-stigma assessment in clinical practice will allow distinctions to be made between the impact of self-stigma and the consequences of schizophrenia to recommend appropriate intervention.
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The higher the level of depression, the more the respondents believed that society devaluates and discriminates against ‘mentally ill’ people. This finding is in line with previous research showing associations between depression severity and stigma beliefs (Aukst-Margetic et al., 2014; Schwenk et al., 2010). We have considered three possible explanations how depression and stigma could be linked: First, within the context of the Cognitive Model of Depression (Beck et al., 1987), depressed persons generally tend to be more receptive to negative evaluation from their social environment (Link et al., 1999; Pyne et al., 2004).
Mental health-related stigma is common and inhibits help-seeking. It triggers fears of devaluation and can add to the burden of a mental disorder. To counter the consequences of mental health-related stigma, its sound assessment is crucial. Therefore, we developed a new measure, the Stigma-9 Questionnaire (STIG-9), and evaluated its psychometric properties and applicability in patients with mental disorders. Item development was based on the modified labelling theory, psychometric reasoning, and discussion with focus groups including patients and clinicians. Data from 919 consecutive patients from an outpatient clinic for mental disorders (69% female, mean age 41 (SD = 14) years) was used to psychometrically evaluate the measure. The STIG-9 consists of nine items assessing cognitive, behavioural and affective aspects of perceived mental health-related stigma. Higher scores indicate stronger expectations of negative societal beliefs, feelings, and behaviours towards ‘mentally ill’ people. Confirmatory factor analysis revealed a single factor structure. The scale showed high internal consistency. Male gender, social impairment and higher levels of psychopathology corresponded with higher STIG-9 scores. The STIG-9 is a new, theory-grounded, patient-oriented and psychometrically promising self-report measure of perceived mental health-related stigma. It is brief, comprehensive, and appears to be well accepted by patients with mental disorders.
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Citation Excerpt :
These personality traits were also reported in case-control studies as being characteristic of patients with schizophrenia (Ohi et al., 2012) and those at ultra-high risk for psychosis (Fresan et al., 2015) rather than healthy controls. Previous studies have shown the correlation between high harm avoidance (Aukst-Margetic et al., 2014; Ohi et al., 2012) and low self-directedness (Ohi et al., 2012), and the severity of depressive symptoms in patients with schizophrenia. The results of these studies were consistent with our current results that childhood abuse influences the development of these personality traits, namely high harm avoidance, low self-directedness, and low cooperativeness on the TCI, and subsequently increases depressive symptoms in schizophrenia.
Previous studies indicated that personality traits have a mediator effect on the relationship between childhood abuse and depressive symptoms in major depressive disorder and nonclinical general adult subjects. In the present study, we aimed to test the hypothesis that personality traits mediate the relationship between childhood abuse and depressive symptoms in schizophrenia. We used the following questionnaires to evaluate 255 outpatients with schizophrenia: the Child Abuse and Trauma Scale, temperament and character inventory, and Patients Health Questionnire-9. Univariate analysis, multiple regression analysis, and structured equation modeling (SEM) were used to analyze the data. The relationship between neglect and sexual abuse and the severity of depressive symptoms was mostly mediated by the personality traits of high harm avoidance, low self-directedness, and low cooperativeness. This finding was supported by the results of stepwise multiple regression analysis and the acceptable fit indices of SEM. Thus, our results suggest that personality traits mediate the relationship between childhood abuse and depressive symptoms in schizophrenia. The present study and our previous studies also suggest that this mediator effect could occur independent of the presence or type of mental disorder. Clinicians should routinely assess childhood abuse history, personality traits, and their effects in schizophrenia.

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

Abstract

Introduction

Section snippets

Participants

Results

Discussion

Psychiatry Research

Journal of Affective Disorders

European Psychiatry

Social Science & Medicine

Psychiatry Research

Psychiatry Research

Comprehensive Psychiatry

Psychiatry Research

Personality and schizophrenia: psychobiological model and its relationship with comorbidity

Psychiatria Danubina

Relations of internalized stigma with temperament and character inpatients with schizophrenia

Comprehensive Psychiatry