Elsevier

General Hospital Psychiatry

Volume 35, Issue 1, January–February 2013, Pages 83-88
General Hospital Psychiatry

Experienced stigma and self-stigma in Chinese patients with schizophrenia

https://doi.org/10.1016/j.genhosppsych.2012.07.007Get rights and content

Abstract

Objective

To investigate experienced stigma and self-stigma in patients with schizophrenia in mainland China.

Methods

Ninety-five patients with schizophrenia, enrolled between January 2011 and March 2011, completed Chinese versions of two self-report questionnaires: the Internalized Stigma of Mental Illness (ISMI) scale and the Modified Consumer Experiences of Stigma Questionnaire (MCESQ). They also completed two other self-report questionnaires: the Social Support Rating Scale (SSRS) and the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Patients were also assessed by a senior psychiatrist using the Scale for Assessment of Positive Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS).

All analyses were performed using SPSS 17.0 and included descriptive statistics, correlation analysis and multiple linear regression.

Results

On the ISMI, the percentage of participants who rated themselves above the mid-point of 2.5 (meaning high level of self-stigma) on subscales and overall score was 44.2% (n= 42) for alienation, 14.7% (n= 14) for stereotype endorsement, 25.3% (n= 24) for perceived discrimination, 32.6% (n= 31) for social withdrawal and 20.0% (n= 19) on the overall score. On the MCESQ, the percentage of participants who rated themselves above the mid-point of 3.0 on subscales and overall score was 24.2% (n= 23) for stigma, 1.1% (n= 1) for discrimination and 1.1% (n= 1) on the overall score. Some socioeconomic variables, but not positive or negative symptoms, were related to the severity of psychiatric stigma.

Conclusions

Results document the seriousness of experienced stigma and self-stigma in persons with schizophrenia. Strategies are needed to improve how governments and persons with schizophrenia cope with stigma.

Introduction

Many factors influence stigma in patients with mental disorders, and cultural context plays an essential role in its formation. Deeply held cultural and philosophical beliefs can promote stigma and act as a barrier to rehabilitation and recovery. In China, traditional cultural values, such as Confucianism, Taoism and Buddhism, strongly influence patients' and society's understanding and interpretation of mental illness and associated stigma. The core virtue in Confucianism, which has shaped Chinese culture for over 2000 years, is filial piety [1]. Filial piety encourages individuals to show respect for their elders and ancestors and to act in an ethical way, in harmony with the self, family, society and the universe. The extreme importance of social harmony and its maintenance take precedence over the expression of one's own opinions and values [2]. People are seen as living first and foremost in a strict network of social interaction (or guanxi). The maintenance of guanxi is dependent on the reciprocal returning of favors [3] which is itself directly related to the concept of “face” (or mianzi). Face is a crucial aspect of social identity and represents power and standing in Chinese social hierarchy. Thus, preserving face or mianzi is a part of daily life. Diagnosis of schizophrenia results in a “loss of face” for the individual [4], and suffering from mental illness is equated with extreme shame in Chinese society.

A review of the literature around the social and cultural history of medicine [5], [6] reveals that psychiatric stigma has existed in Europe since the times of Ancient Greece and the Middle Ages. Such stigma continues to be prevalent in Western countries [7]. Psychiatric stigma not only leads to negative stereotyping and to discriminatory behavior towards those affected by mental illness [8], [9], but causes feelings of shame in patients, both of which result in decreased life satisfaction and self-esteem [10]. Rehabilitation in schizophrenia patients is often hampered by stigma-related difficulties [11]. Stigma refers to the experience of discrimination by patients and the resulting limited social participation [12]. Self-stigma mainly refers to the internalization of public stigma. Corrigan [13] defines self-stigma as the internalizing of shame, blame, hopelessness, guilt and fear of discrimination associated with mental illness. It has also been described as a process, wherein the patient alters both what they expect of themselves and how they expect to be treated by society [14].

It is very common for those with mental illnesses to experience discrimination, as reported in findings in Hong Kong [15], [16], Mainland China [17], [18], as well as in the Western literature [[9], [19]]. However, the extent and nature of stigma and self-stigma in schizophrenia patients in China are still largely understudied. In particular, previous research has used nonstandardized questionnaires, making between-study comparisons difficult. For these reasons, our study measured stigma in a Chinese setting using two standardized questionnaires and describes the characteristics of stigma, self-stigma and other relevant factors. We discuss recommendations for policy around stigma prevention, especially related to patients' reintegration into society.

Section snippets

Participants

A nonprobabilistic sampling method was used to recruit participants. The participants were inpatients or outpatients with schizophrenia receiving treatment in the Second Xiangya Hospital between January and March 2011. For inclusion, the patients had to be (1) diagnosed with schizophrenia. Patient assessments were done by a psychiatrist using the DSM-IV criteria (American Psychiatric Association, 1994), and diagnoses were independently confirmed by a psychologist in a structured clinical

Participants' characteristics

An overview of the participants' sociodemographic and clinical characteristics is shown in Table 1.

Level of self-stigma

Mean scores on the ISMI were as follows: 2.29 for alienation (S.D.=0.49), 2.07 for stereotype endorsement (S.D.=0.44), 2.15 for discrimination experience (S.D.=0.45) and 2.19 for social withdrawal (S.D.=0.46) The mean overall score was 2.17 (S.D.=0.38).

The percentage of participants who rated themselves above the mid-point of 2.5 on the subscales and total scores of the ISMI (i.e., high level of

Discussion

Our study aimed to explore psychiatric stigma among Chinese patients with schizophrenia and factors influencing such stigma. In this study, nearly 70% of respondents reported mild or moderate self-stigma. Although this is comparable to findings in Spain [32] , a study including 14 European countries found higher levels of self-stigma, with 41.7% reporting moderate or high levels of self-stigma [33]. On the ISMI, over 60% of patients “agreed” or “strongly agreed” with “Living with a mental

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