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Articles   |    
Well-Being Among Persons at Risk of Psychosis: The Role of Self-Labeling, Shame, and Stigma Stress
Nicolas Rüsch, M.D.; Patrick W. Corrigan, Psy.D.; Karsten Heekeren, M.D.; Anastasia Theodoridou, M.D.; Diane Dvorsky, Ph.D.; Sibylle Metzler, Ph.D.; Mario Müller, Ph.D.; Susanne Walitza, M.D., M.Sc.; Wulf Rössler, M.D., M.Sc.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300169
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With the exception of Dr. Corrigan and Dr. Walitza, the authors are with the Department of Psychiatry, Psychotherapy, and Psychosomatics, University Hospital of Psychiatry, Zürich, Switzerland. Dr. Rüsch is also with the Department of Psychiatry II, University of Ulm, Ulm, Germany (e-mail: nicolas.ruesch@uni-ulm.de). Dr. Rössler is also with the Laboratory of Neuroscience, LIM27, Institute of Psychiatry, University of Sao Paulo, Brazil. Dr. Corrigan is with the Illinois Institute of Technology, Chicago. Dr. Walitza is with the Department of Child and Adolescent Psychiatry, University of Zürich, Zürich.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  When young people at risk of psychosis experience early signs of the disorder or early intervention, they may label themselves as “mentally ill.” However, empirical data related to the potentially harmful effects of self-labeling and stigma among young people at risk of psychosis are lacking. This study used a stress-coping model to examine mechanisms by which stigma may exert an impact on young people at risk of psychosis.

Methods  The authors assessed self-reports of perceived public stigma, shame about having a mental illness, self-labeling, and the cognitive appraisal of stigma as a stressor (stigma stress) as predictors of well-being among 172 residents of Zürich, Switzerland, who were between 13 and 35 years old. All participants were at high risk or ultra-high risk of psychosis or at risk of bipolar disorder. Psychiatric symptoms were assessed by the Positive and Negative Syndrome Scale, and well-being was measured by instruments that assessed quality of life, self-esteem, and self-efficacy.

Results  Perceived public stigma, shame, and self-labeling were independently associated with increased stigma stress. More stigma stress, in turn, predicted reduced well-being, independent of age, gender, symptoms, and psychiatric comorbidity. Stigma stress partly mediated the effects of perceived public stigma, shame, and self-labeling on well-being.

Conclusions  Perceived public stigma, shame, and self-labeling appear to be associated with stigma stress and reduced well-being among young people at risk of psychosis. With early intervention programs gaining traction worldwide, effective strategies to address the shame and stigma associated with at-risk states and early psychosis are needed.

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Figure 1 Model of public stigma, shame, and self-labeling as predictors of stigma stress and reduced well-beinga

a Solid lines indicate the indirect pathways from predictor variables (a1, a2, and a3) to well-being, mediated by stigma stress (b). Dashed lines indicate the direct pathways from predictor variables (c1, c2, and c3) to well-being. Stigma stress results when perceived harm from stigma exceeds perceived coping resources. Self-labeling refers to labeling oneself as “mentally ill.”

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Table 1Bivariate correlations of predictors of stigma stress and cognitive appraisals of stigma as a stressor among 172 persons at risk of psychosisa
Table Footer Note

a Stigma stress was calculated by an 8-item scale with 4 items measuring perceived coping resources (mean±SD=4.9±1.2, Cronbach’s α=.77) and 4 items measuring perceived harm (3.4±1.6, Cronbach’s α=.92). Scores for coping (secondary appraisal) are subtracted from scores for harm (primary appraisal) to yield a single stigma stress score.

Table Footer Note

b Measured by the Perceived Devaluation-Discrimination Questionnaire (24). Possible mean scores for each item range from 1 to 6, with higher scores indicating more perceived public stigma (Cronbach’s α=.90). Williams’ test of |r12| versus |r13| indicated that perceived public stigma was significantly more strongly associated with the primary versus the secondary appraisal (t=3.19, df=169, p=.002).

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c Measured by the statement “I would feel ashamed to have a mental illness.” Possible scores range from 1, not at all, to 9, very much.

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d Labeling oneself as “mentally ill” was measured by perceptions of one’s mental health. Possible scores range from 1, “I am perfectly mentally healthy,” to 9, “I am severely mentally ill.”

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*p<.05, **p<.01, ***p<.001 (two-tailed)

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Table 2Predictors of stigma stress among 172 persons at risk of psychosis
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a Model R2=.31

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b Step 2 of the regression controlled for age, gender, positive and negative symptoms, and comorbid psychiatric disorders. Model R2=.40

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c For interpretation of the meaning and direction of the correlation coefficient, 0=no depressive disorder and 1=depressive disorder

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d For interpretation of the meaning and direction of the correlation coefficient, 0=no anxiety disorder and 1=anxiety disorder

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Table 3Predictors of well-being among 172 persons at risk of psychosis
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a Model R2=.20

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b Step 2 of the regression controlled for age, gender, positive and negative symptoms, and comorbid psychiatric disorders. Model R2=.34

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c For interpretation of the meaning and direction of the correlation coefficient, 0=no depressive disorder and 1=depressive disorder

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d For interpretation of the meaning and direction of the correlation coefficient, 0=no anxiety disorder and 1=anxiety disorder

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Table 4Pairwise regression analyses of the effects of independent variables on well-being with or without the addition of stigma stress as a mediator
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a Pathways in the stress-coping model of mental illness stigma by which stigma may affect well-being (Figure 1)

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b Sobel tests of stigma stress as mediator were significant (p<.001).

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c The Sobel test of stigma stress as mediator was significant (p=.002).

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