Comparison of Total Self-Stigma Between Schizophrenia and Alcohol Dependence Patients

Stigma is defined as “an attribute that is deeply discrediting,” where a person is lowered “from a whole and usual person to a tainted, discounted one” (1). It is divided into public stigma and self-stigma. Public stigma is the reaction of the general population towards people with mental illness. Self stigma is the prejudice, in which people turn against themselves. Stereotypes, prejudice, and discrimination are the three components of both self and public stigma (2). Patients experiencing stigma suffer consequences such as increased social isolation, decreased treatment access, and limited life chances. The sources of stigma include community, co-workers, family, mental health caregivers, religious places, etc. (3, 4). Internalized stigma or self stigma has also been related with negative outcomes such as depression, social avoidance and avoidance coping, decreased hope and self-esteem, decreased access to mental health services and other supports, as well as worsening of psychiatric symptoms (5-8).

A number of previous studies reported rise of self-stigma in psychiatric disorders in recent years (9, 10). These studies were conducted homogenously on schizophrenia and spectrum disorders while others focused on non-homogenous mental disorder groups such as schizophrenia, mood, personality, and anxiety disorder subjects (11, 12). As compared to other psychiatric disorders, the patients with schizophrenia experience more stigma (13, 14). A recent study reported the prevalence of internalized stigma to be 29.4% among schizophrenia patients (15). The literature reported that inter-individual and intra-individual variables might decrease or increase the stigma impact on health-related outcomes (16). It has been found that socio-demographic factors are marginally related to personal stigma and on the other hand psychosocial variables such as quality of life inversely related to personal stigma. The variables such as age of onset, lifetime number of hospitalization, and duration of illness reported significant associations with personal stigma (17, 18).

In contrast to schizophrenia patients, literature investigating self-stigma in alcoholism is limited. Alcohol dependence is one of the most common mental disorders (19). Alcoholism has a negative impact on social behavior, social environment, and social interactions (20). The stigma related to alcoholism may hinder the seeking of professional help; increasing these effects and experiencing discrimination and loss of status. Therefore, it may lead to social exclusion, particularly in those who need social support (21). As compared to other psychiatric illnesses, people with ADS face strong rejection and negative stereotypes like being unpredictable or being danger (22, 23). Stigma ascribed to patients with substance use contributes to non-completion of treatment, poor mental and physical health, poor reintegration and recovery processes, and increased involvement in risky behavior (24, 25).

This study was done due to the fact that a number of attempts have been made to measure attitude toward psychiatric illness and stigma, particularly held by people in the community, a family member, and a caregiver rather than the patients themselves (26, 27); comparative studies among persons with different mental disorders show that their attitudes are illness specific (23, 28); and we might expect differences in the demographic variables of stigma related to other mental disorders compared with demographic variables of alcohol disorder stigma (29). In our set up, we get patients mostly suffering from schizophrenia and ADS, with higher dropout rates and poor compliance. Therefore, we choose these two groups of patients in this study. To the best of our knowledge, there are no studies comparing stigma in schizophrenia and alcohol dependence syndrome (ADS). Developing an understanding into the stigma of these disorders will be important to help these individuals, their family members, caregivers, and treatment providers. Thus, in this study we tried to find out how stigma of schizophrenia compare with stigma of alcohol dependence syndrome.

The present study aimed to comparison of total self stigma between schizophrenia and alcohol dependence patients.

A cross sectional study was performed on patients attending the Psychiatry unit of Acharya Vinoba Bhave Rural hospital, Wardha, Maharashtra during the period of April- June 2016. The study was conducted on obtaining the institutional ethics committee approval and patient’s written informed consent after providing necessary information. A total of 100 patients, aged 18 to 60 years, who were able to read and understand Hindi, were selected through purposive sampling as per the inclusion and exclusion criteria of the present study. Of the total patients, 50 were diagnosed as schizophrenia and 50 as alcohol dependence syndrome for comparison according to international classification of diagnostic criteria (ICD-10). The patients having co-morbid medical or other psychiatric illness, un co-cooperative, organic brain syndrome, mental retardation, and in need of emergency medical care were excluded from the study.

This study attempted to measure and compare self stigma among schizophrenia and alcohol dependence syndrome patients. Researches related to perceived self stigma in psychiatric disorders generally conducted were neither on a homogenous group of illness nor comparative studies. To the best of our knowledge, it is the kind of first study conducted.

A review of literature reported internalized stigma in schizophrenia patients to be 29.4% and 41.7%, respectively (15, 32). Literature of the comparative studies on stigma of alcoholism and other psychiatric disorder show that people suffering from alcohol dependence are severely stigmatized (33-35). Rohit et al., in his study also reported that substance dependence patients had higher stigma scores than schizophrenia patients (36). The present study determined internalized stigma in 50% of schizophrenia patients and 66% of ADS patients. The stereotype endorsement (0.01), stigma resistance (0.023), and total ISMI scores (0.21) were found to be statistically significant between the two groups. Compared with the above studies, a high prevalence of self stigma was found in our study, which could be due to the heterogeneity of the sample and differences in severity of illness (37). Our study also reported that the prevalence of stigma in ADS was higher than schizophrenia. This may be due to the fact that they provoke more social rejection and more negative emotions, they are held much more responsible for their condition, less frequently considered as mentally ill, and at risk of structural discrimination (35).

The present study reported significant association of self stigma with marital status, education, type of family, and locality among schizophrenia patients whereas self stigma scores were not significantly affected by other socio-demographic variables. Different studies across the world correlating stigma with socio-demographic variables have found contrasting results. In these studies, self stigma was significantly associated with age and male gender (17) whereas some suggest lack of association with being married, living alone, and education (38-40). In addition, in a study by Rohit Garg et al., significantly higher stigma scores were reported in younger patients than older patients. This may be due to the fact that there are more understanding about their friends and more social interactions focusing on self attributes at a younger age (36). Previous studies also reported more stigma in patients with lower education than those with higher education (41, 42). It may be due to lower socioeconomic status and poverty in individuals with lower education. They are dependent on others for their employment and placed at the bottom in social hierarchy. This may contribute to a greater degree of social rejection, isolation, and internalization of feelings of stigma (36).

A study by Jadhav et al., showed higher stigma scores in rural samples than the urban sample. The reason may be that rural subjects showing supportive tolerant attitude as indicated by not covering up the illness, favorable response to living next door, and expecting the full return to normality (43). The rural individuals experienced more shame, ridicule, and discrimination whereas urban individuals felt the need to avoid and hide their illness in their job application (44). The reason for no significant association found in our study with respect to other variables may be due to socio-cultural and methodological differences.

The present study reported lack of association with clinical characteristics such as current status and illness duration among schizophrenia patients. Previous studies observed higher stigma scores in patients with longer illness duration and those who were not in remission (36). A review by Gerlinger et al., reported that age of onset, lifetime number of hospitalizations, and duration of illness had contradictory associations with self stigma (17). All these factors would be expected to increase the number of symptoms and severity of illness as well as expected to increase the actual stigmatizing responses of others and the person’s stigma (36). The differences found in our study and previous studies in relation to clinical characteristics could be attributed to different questionnaires used to assess the stigma and differences in the psychosocial factors (45, 46).

Our study demonstrated that self stigma was significantly related to educational status of ADS patients, whereas none of the other socio-demographic variables had a significant difference. Previous studies suggested that stigma was significantly higher for men, individuals with lower income, lesser education, and individuals previously married as compared to those who had never been married (47). Consistent with these findings, the literature also suggested that women and persons with higher education and income are generally more accepting of individuals with mental illness. Corrigan et al., hypothesized that lower endorsement of stigmatizing attitudes towards women may be due to a lower rate of social dominance among women and/or higher rates of social empathy compared with men (48-50).

Stigma in people with substance use disorders lead to non-completion of treatment, poor recovery, and reintegration processes (24, 25). Literature also suggested that stigma lead to more difficulties in recovery, greater chances of relapse, and discontinuation of treatment (51, 52). The above findings conclude that stigma negatively influences the clinical parameters such as duration of the drinking and status of the illness among alcoholics. The present study did not report correlation between clinical variables and stigma among ADS patients. Literature on self stigma is more sparse in addiction and no study showed direct correlation of self stigma among ADS with clinical variables.

The correlation of socio-demographic and clinical variables between schizophrenia and ADS patients with self-stigma in our study reported no significant difference except for gender. This may be due to the fact that male participants outnumber females out of total sample size in this study. The logistic regression analysis showed that locality was found to be a predictor of stigma in schizophrenia, whereas locality and educational status were significant predictors of stigma in ADS in the present study. The results of regression analysis of previous studies demonstrated that current employment, gender, and level of education were not significant independent predictors of self-stigma in schizophrenia (32). Although the personal characteristics are of lesser importance to the formation of self-stigma, drinking related variables such as duration of drinking problem is found to be an independent predictor of stigma in ADS (53). Our scan of literature revealed no studies comparing schizophrenia and ADS patients in terms of having self-stigma. Therefore, further studies with large number of patients are needed to clarify whether differences occur between these disorders in terms of self-stigma.