Stigma, society and schizophrenia

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Stigma, society and schizophrenia

Wednesday, 24 May 2023 | R C Jiloha

Stigma, society and schizophrenia

Reduction and eradication of stigma attached to schizophrenia requires a concerted effort at the individual, societal and institutional levels

World Schizophrenia Day is observed every year on 24th May 1984 to educate the public about Schizophrenia and challenge the misconceptions and stereotypes surrounding the disease. In 1911, Eugen Bleuler, a Swiss psychiatrist, coined the term schizophrenia for patients with severe mental disorders having lost their contact with reality. The illness is characterized by hallucinations, delusions, disorganized thinking, cognitive and motivational impairment, poor social functioning and social isolation. The illness generally begins during adolescence and takes a chronic and often deteriorating course if not treated adequately on time.

Today, more than 21 million people across the globe live with this label and more than half of them remain untreated because of various reasons including the stigma attached to the illness. Before Bleuler, people with schizophrenia were variously named and treated with varying degrees of discrimination and prejudice.

The stigma attached to schizophrenia is a disgraceful attribute that makes the patient an acceptable target for prejudice, deprivation and discrimination. Stigma could be subtle or obvious – but no matter the magnitude, it can lead to a damaging effect on the prognosis of the disease. Stigma often comes from a lack of understanding or fear, and inaccurate or misleading media representations that make society to under-evaluate persons with schizophrenia. Self-stigma occurs when the patient internalizes negative attitudes about one’s condition and views himself as flawed and deficient compared to others. This leads to the subjective feeling of emotional embarrassment, erosion of self-esteem and social status and alienation.

These conditions contribute to unemployment, isolation, poor need for treatment or delayed treatment, prolonged illness course and avoidable hospitalization. Public stigma involves negative or discriminatory attitudes that others have about the patients which result in social rejection and isolation due to emotions of anger, anxiety, pity, or fear elicited in other people. Institutional stigma involves policies of the government and private organizations that intentionally or unintentionally limit opportunities for people with schizophrenia. It becomes evident when institutional practices result in discrimination in employment opportunities and other benefits. Institutional attitude contributes to the worsening of the disease and reduces the likelihood of seeking help. The combination of internalized, interpersonal, and institutional stigma has a synergistically corrosive effect on mental and physical health that extends far beyond clinical symptoms.

The most common consequences of stigma are anger, depression, fear, anxiety, feelings of isolation, guilt, embarrassment, and prevention from recovery or avoidance of help-seeking. Stigmatized individuals often deplete adaptive coping mechanisms while managing a devalued identity and thus engage in maladaptive emotional regulation strategies such as rumination, and daydreaming, increasing their risk for other adverse health outcomes. Also, the fear that making the illness public will decrease job opportunities and social status, makes the patient more anxious. 1 in 3 patients with schizophrenia has a social anxiety disorder, and stigma is closely related to social anxiety in these patients. Prejudice and discrimination related to schizophrenia result in an increased probability of misuse of alcohol and drugs.

Stigmatization has detrimental consequences for both objective and subjective quality of life. Reduced subjective quality of life in schizophrenia is mediated by perceived stigma and lower self-esteem. Anxiety disorders impose an additional burden, resulting in a further decline in their subjective quality of life. There are several barriers in the way of removing stigma. Some of these stem from the biased attitudes and practices of mental health professionals themselves. Mental health workers may develop negative attitudes toward the patients they treat. Even physicians affected by mental illness suffer from interpersonal stigma due to a deep-rooted view in the medical profession that disclosing mental health issues means admitting constitutional weakness which may erode their reputation as physicians.

There are multiple pathways for overcoming negative attitudes and practices. These include improved training in evidence-based interventions, engaging in a collaborative and empathic relationship focused on patient empowerment, and the provision of psychological support for mental health professionals in response to daily stresses. A significant barrier to removing interpersonal stigma is the paucity of social contact with stigmatized individuals. If people contact stigmatized individuals in conditions of relatively equal power and status, the interaction is far more likely to generate positive attitudes and chip away at stigma. Regular, informal contact is most likely to eradicate negative perceptions of stigmatized individuals. Shared goals and cooperative work toward common ends between people with and without mental illness promote an environment where attitudes are more likely to be positive and contact is likely to continue.

At the institutional level, in India, several measures have been instituted to remove or at least minimise the stigma against mental disorders. National Mental Health Program 1982, National Mental Health Policy 2014 and Mental Healthcare Act 2017 - all recognise stigma as a significant barrier to achieving mental health and provide strategies to reduce stigma such as integration of mental health with general health services, community participation and empowering mentally ill with their rights. These strategies have been implemented, focusing principally on improving knowledge about mental health as well as attitudes toward individuals with schizophrenia.

The integration of mental health into primary care identifies positive effects on healthcare professionals’ attitudes as well as in connecting patients with health services and self-help groups. Advocacy to reduce public stigma is most effective if promoted with the possibility that individuals with schizophrenia can attain the role expectations with proper support.

Stigma is a form of social injustice that contributes to the onset of psychosis in schizophrenia spectrum disorders, delays treatment attainment, promotes social isolation, stress, and maladaptive coping behaviours such as alcoholism and drug addiction, and places individuals with schizophrenia at higher risk for a more severe illness course resulting in a vegetative state. Reduction and eradication of stigma requires a concerted effort at the individual, societal and institutional levels. Patients with schizophrenia require access to high-quality and affordable care. Effectively integrating these factors can decrease symptom burden, reduce discrimination, and promote helpful social contact.

(The Writer is a former professor of Psychiatry University of Delhi and Jamia Hamdard)

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