Mental Health Stigma Varies by Diagnosis, Driven By Fear and Misunderstanding

A new study finds varying levels of stigma for different mental health diagnoses. But, stigma is consistently driven by fearful attributions.

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In a new article published in BJPsych Open, Cassie M. Hazell and colleagues explore how levels of mental health stigma differ depending on the psychiatric diagnosis a person receives. The authors used an online survey given to 665 participants to assess their levels of stigma for nine different vignettes representing varying psychiatric diagnoses.

The researchers found that schizophrenia and antisocial personality disorder were the most stigmatized diagnoses. Depression, generalized anxiety disorder, and obsessive-compulsive disorder were associated with the lowest levels of stigma.

The authors note that fear was the most consistent predictor of stigma and conclude that anti-stigma campaigns should target fearful attributions. They write:

“No single attribution predicted stigma across diagnoses, but fear was the most consistent predictor. Assessing mental health stigma as a single concept masks significant between-diagnosis variability. Anti-stigma campaigns are likely to be most successful if they target fearful attributions.”

Mental health stigma can lead to discrimination, worsening symptoms, and generally less desirable outcomes. Research has shown that social stigma can negatively affect and increase the distress associated with the experience of hearing voices. People with mental health diagnoses that are able to resist the stigma associated with their diagnosis enjoy better outcomes than their less fortunate counterparts.

Essentialist thinking – the assumption of an underlying essence that defines a thing – likely drives stigmatizing attitudes towards schizophrenia. The biomedical model of mental illness increases the stigma around mental health diagnoses by defining psychological suffering as essentially a problem of broken brains. The biomedical model is similarly linked to discrimination based on psychiatric diagnosis.

Where mental health literacy fails to reduce stigma, psychosocial explanations (those framing “mental illness” as a social problem rather than a medical one) may be more effective. For example, one study found that psychosocial explanations of psychosis reduced stigma compared to biomedical explanations. Another piece of research found that viewing mental illness on a continuum rather than as discrete categories of “mentally ill” and “mentally healthy” helped to reduce stigma.

While psy-professionals have recognized the damaging effects stigmatizing attitudes can have, those attitudes have remained relatively stable over the last few decades, with many anti-stigma campaigns failing to make a measurable impact. Some sociologists have argued that anti-stigma campaigns enable inequality by ignoring the social causes of mental illness. In addition, authors have noted that some advocacy groups claiming to combat stigma around mental illness are, in fact, disguised pharmaceutical companies pushing drugs under the banner of patient welfare.

The current work begins by defining mental health stigma as ignorance, prejudice, and discrimination towards those with a mental health diagnosis. Stigma negatively impacts numerous areas of the sufferers’ life by reducing help-seeking, increasing unemployment and healthcare costs, and worsening mental and physical health. The authors sought to understand better how levels of stigma differ with varying psychiatric diagnoses and what attitudes inform and could possibly predict stigma.

The authors recruited 665 participants to take a survey designed to assess how much they sought distance from those with varying mental health diagnoses, how much personal responsibility they attributed to such individuals, and the levels of fear, anger, and pity they associated with each diagnosis. All participants were 18 years old or older and lived in the United Kingdom. The participants were recruited using social media and survey-sharing sites. In terms of demographics, the participants were overwhelmingly white, British, employed, and single females.

The current study found that schizophrenia and antisocial personality disorder were the most stigmatized mental health diagnoses, with depression, generalized anxiety, and obsessive-compulsive disorder showing the lowest levels of stigma. In line with previous research, stigma was generally more robust in cases of “serious mental illness” (i.e., psychosis) and weaker in cases of “common mental health problems” (i.e., depression).

Where previous research has framed stigma as a result of decreased pity, increased fear and anger, and a belief that people with a mental health diagnosis are personally responsible for their symptoms, the current research finds that fear is the single strongest predictor of stigma. While believing the person with a diagnosis to be personally responsible for their symptoms predicted stigma in some cases, fear predicted stigma in nearly all cases.

The authors note several limitations with the current research. The participants were predominantly white, female, educated, and employed. This demographic tends to associate less stigma with mental health diagnoses than the population generally. One-quarter of the participants had one of the diagnoses discussed in the survey, possibly activating a confounding self-stigma variable. The vignettes described a prototypical textbook example of a mental health diagnosis which is likely to be very different from how these diagnoses present in real life.

The authors conclude that anti-stigma campaigns would likely be more effective if they treat each diagnosis individually rather than treating “mental health stigma” as one entity. They also note that the hierarchy of stigma they created here could benefit from the knowledge of someone with first-hand experience of mental health stigma. They write:

“These anti-stigma campaigns are likely to be most effective if they take a diagnosis-specific approach, based on our regression models and the attributions found here to significantly predict stigma. The application of this hierarchy in the real world would benefit from input from those with lived experience to avoid its misuse in terms of prioritizing the impact of stigma on someone with a particular diagnosis over another.” 

 

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Hazell, C., Berry, C., Bogen-Johnston, L., Banerjee, M. (2022). Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma. BJPsych Open, 8(174). DOI: 10.1192/bjo.2022.578 (Link)

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Richard Sears
Richard Sears teaches psychology at West Georgia Technical College and is studying to receive a PhD in consciousness and society from the University of West Georgia. He has previously worked in crisis stabilization units as an intake assessor and crisis line operator. His current research interests include the delineation between institutions and the individuals that make them up, dehumanization and its relationship to exaltation, and natural substitutes for potentially harmful psychopharmacological interventions.

13 COMMENTS

  1. I sometimes do not mind if people want to fear me. I know of one schizophrenic who shines their diagnosis like a torch light if they happen to be outside walking the city streets late at night. They yell that they are schizophrenic and get left in peace to enjoy their saunter.

    I have known persons who demand that I do not stigmatize or fear them but love them unconditionally. Bullies often demand you don’t stigmatize them for behaving badly. Such as the time I was assaulted.

    So it is a complex subject really. We need to be able, as a community, to stigmatize certain appalling bad behaviours like rape.

    So I am not for the sweeping notion that ALL stigma is like a phobia. People should be free to fear whomever they have a feeling of fear about. Indoctrinating people out of healthy fear is adding to the numbing down of normal emotions. But emotions are not outward behaviour. Outward behaviour can be atrocious, especially when that person behaving badly is disconnected from their feelings, particularly the feelings that form caring. Outward bad behaviour must be banned because it is bullying. But there is only an intensification of resentment if a person is told they are not allowed to feel their own phobic fear. A felt feeling moves swiftly on and becomes a new feeling. Supressing the inner feeling of fear is leads to more and more numbness, as a defence against feeling anything at all. It is the numb who act with outward bad behaviour and cruelty. The numb cannot care. The feeling can care, even if fear is mixed into the mishmash of emotions churned up.

    We stigmatize all the time in our inner chats with ourselves as we go shopping in a mall and encounter a vast variety of people who we like and people who we mistrust. That inner stigmatizing is harmless. Ill tempered two year olds and octogenarians do this inner snubbing of strangers. It is animal wariness. But when it becomes outward bullying behaviour “that” is when it can be an aggressive or oppressive action. But outward behaviour need leverage to spring out. That lever is not the feeling of fear but is “a thought”. A thinking decisively to act externally. The thought might be using the feeling of fear as a stepping stone by convincing the self that…

    “yes…that hat wearing odd individual really is a criminal”.

    A feeling of fear is an internal state that cannot hurt anyone. Once the mind includes a paranoid “thought” to that feeling of fear only THEN outward behaviour can leap into action.

    You may never get rid of the human propensity to occasionally fear others and even stigmatize them inwardly, not without making things worse, via numbing, which then escalates into supressed wishes to act cruelly. But you can BAN cruelty. You can BAN outward bad stigmatizing behaviour. But you cannot force someone to love you or force someone not to fear you. You cannot force feelings. You can only make someone ill by policing their inner emotions. Feelings happen too fast to checkpoint them. You can get someone to give their own feelings a row or get them to be embarrased by those feelings but this often either has them lidding their feelings in a toxic blockage or it brews resentment or it causes numb cruelty.

    I have been on an art retreat scenario where the other residents formed a whispering bubble of conniving contempt against me simply due to the fact that I introduced myself as schizophrenic. Their loss. Eejits! I found it quite funny. Wrote a ten page poem about their snooty pushy assumption that psychosis is an imbecilic condition. They were going from just fearing me to thinking up idiotic ideas about me and smirkingly telling me how to use a teaspoon properly.

    We will know more when The Hoover Dam gets exploded. The stigmatized always have the last laugh.

    • I also want to say that stigma over difference is much like discernment. Stigma is part of a community guarding the vulnerable against violation or rape or abuse. A community DOES need to stigmatize monstrous bad behaviour such as when someone is so mixed up they try to drown themselves and their children in a car in the incoming tide. All rural, indigenous, ancient tribes and communities use SHAME as a powerful deterent to child abuse and murder. Not all forms of shaming or stigmatizing are harmful to the community. I am not sure if this is a yarn but I once heard that the people of some icy climates apparently shame young children who veer too near to the edge of a frozen lake by getting the whole community to laugh at them. That is a recognition of the life saving, guarding, healthy application of shame. These days a young man in a community can have several thousand downloads of kiddy porn and feel no shame whatsoever. A community that shames all instances of shaming is destined for collective depravity.

      What stigma is is a reflex noticing of difference and then deciding that the difference means badness. Mostly it is not true that there ever is any badness. But sometimes a mixed up person does not realize that they are being bad. A very young child abuser who is also still a child may think they are doing their classmates a big favour by introducing them all to the joys of copulation. What do we as a community do then eh? Tell them all it is ok to make babies? A few weeks back a child became a proud father at the age of eleven.

      I say someone was a coward not to stigmatize his bad behaviour much much earlier. A poor little baby is going to have to live with the fact its parents were not old enough to skip school to make cup cakes let alone new human beings.

      I would rather live in a community that overly stigmatizes than does not stigmatize anything. But the BALANCE between these extremes will always cause bickering. That arguing over the dividing line between laxity and heavy handed convention or rules always does need to stay topical and open for discussion. But rape and murder and abuse cannot be permitted in a community without the undoing of that community. Crimes of that magnitude cannot be welcomed as if healthy.

      The overly stigmatized can be harmed of course, of course. But the lack of any prudence can cause equal harm, if not moreso.

      Many on this website feel injustice in the area of stigma and seek to stigmatize the stigmatizers or shame the shamers. In many instances in our picky modern ill society it is healthy to judge the overly judgemental since judgmentalism can also be a form of abuse.

      All of these strands are important considerations that cannot be summed up in a tidy comment. Summing up is for inflexible communities. A healthy community stays flexible enough to keep applying good balance. But what cannot be left to nonchalant flexible fashion is the rule against the three worst ways to behave. Bullying, sexual abuse, cruelty. These three must stay banned. They erode individuals and they erode communities. If a person is mixed up in that way then the stigma is what they themselves need, to begin to shun within themselves, their own worst behaviour. Their recovery depends upon them finding such behaviour in them odious and loathesome or they will never redeem themselves.

      Psychotherapy has spawned an idea that love fixes everything. But sometimes loveless shaming is healthy in regard to loveless bad behaviour of a devastating sort.

      As society messes up all over the world quite soon humanity will be able to glaringly see all of this play out. When the whole world becomes a trafficked orgy the old adage of…

      “Have you no shame?”

      will sound appealing again.

      What is going on in the world now because of the wrong kind of shamelessness is a recipe for DISASTER.

  2. “While psy-professionals have recognized the damaging effects stigmatizing attitudes can have, those attitudes have remained relatively stable over the last few decades, with many anti-stigma campaigns failing to make a measurable impact.”

    Maybe because the same populations who mount the anti stigma campaigns are the ones who create and feed the stigma in the first place, as in:

    “Personality Disorder (PD) is a thorn in the flesh of many clinicians as, however, they may wish to avoid managing those with such a diagnosis, those with personality disorder label have a tenacious hold on the clinician. While only a small minority of PD patients actively seek treatment – although often in a dysfunctional manner – the majority avoid contact with health professionals but nonetheless cause considerable distress both to themselves and those around them. The uncertain nature of PD diagnosis and the unproven nature of its treatment results in psychiatrists being ‘dammed if they do’ (i.e. getting involved then being blamed for the subsequent outcome) and ‘dammed if they don’t’ (i.e. avoiding responsibility and hence being blamed for the subsequent outcome). This course is aimed to equip clinicians with a rational and defensible approach in the management of this group.”

    This is actually a pretty tame example of the disparaging treatment of those diagnosed with personality disorders by those who do the diagnosing.

    Two thoughts:

    If the stigma is born out of the diagnosis and not anything the person has actually said or done, the way to get rid of the stigma is to get rid of diagnoses, which have already been revealed as completely subjective, biased, unscientific. Get rid of the DSM.

    And, instead of trying to decrease stigma of those labelled as mentally ill, which has been tried and talked about for decades without success, instead increase stigma againsts the groups responsible for the stigma. Increase stigma againsts psychiatrists who break the Hippocratic oath, who fail to provide informed consent, or outright lie to their patients. Increase the stigma against the FDA who approved the Prozacs and the atypical antipsychotics on the market with no warnings to consumers, who allowed fraudulent advertising, etc. Increase the stigma against the drug manufacturers. Increase the stigma against NIMH, that had billions in taxpayer money to “solve mental illness” and have nothing to show for it. Increase the stigma against the large portion of the general public that continues to allow itself to be brainwashed into believing that mental illness is a medical problem requiring adherence to a medication regimen.

  3. “People with mental health diagnoses that are able to resist the stigma associated with their diagnosis enjoy better outcomes than their less fortunate counterparts.”

    Why is it the labelled person’s job to resist the stigma? What does this mean? Accept the diagnosis but resist the stigma (when the two are inseparable)? Shut up and take your meds? Or dare to be “non compliant”, drop out of treatment, and live in fear, in hiding for the rest of your life?

    We don’t tell people of color that they’ll have better outcomes if they resist racism.

    I’m sick of psychiatry, sick of society. The borderline diagnosis and everything that came with it destroyed my life, my health, my future. 15 years on, 56 years old, and now I know I’ll be carrying all of this til I’m dead. Left sick, broken, hopeless and alone. Thanks psychiatry. Burn in the hereafter.

  4. hmmm…yeah, I remember when my wife first suggested she might have DID and I immediately wondered if I was living with a psychopathic murderer(thanks, Hollywood!). Fortunately, I realized almost immediately that I had safely lived with her for 20 years and she was unlikely to kill me in my sleep at that point if I hadn’t given her reason before then…

    Sadly, the fear of stigma has kept my wife in the shadows, unwilling to give up the appearance of ‘normalcy’ by those in our lives…and though I have discussed with her multiple times how beneficial it would be for us to have more support as well as sharing our mutual healing journey on a larger scale because so many are struggling and it’s only gotten worse since COVID, she just is unwilling to live with the caricature our culture places upon those with a diagnosis…especially since hers is one of the ‘worst’.

    But for me, seeing our commonality and learning much from her own struggles helped me become a better, healthier person partially so that I could be a better healing companion with and for her on this journey…

    And I have been given the opportunity to share our journey on a larger scale using this pen name as I have begun collaborating with an expert (since I’m just a husband), but also because she brings a lot to this project, to write a book together and one of our goals is to normalize mental health struggles and living with someone even experiencing pretty extreme stuff like my wife did…and perhaps someday we’ll see the fruit of that venture if we make it to the goal.
    Sam

    • Sam, I do not know your wife so excuse me using my imagination here. I like how you are a sheild for your wife whom I accept in my imagination as perhaps just “shy”. Advocates in advocacy have sheilding the shy as their very point and purpose. The shy are often the most marginalized and stigmatized of all. You bear the secondary stigma that your possibly shy wife might get if she voiced her painful suffering of her debility and this, your bearing of undeserved stigma for being her advocate, is very noble of you.

      Your words are valuable as a resourse on DID.

      • Thanks, Diaphonous Weeping,
        I try so hard. It’s really hard being attacked for doing the very thing, I believe, many on this website wishes their own spouses and families had done for them: doing whatever, and I mean whatever, it takes to love them, protect them, respect their agency, keep their dignity, and just treat them like a normal human being despite all the extreme states, dissociation and, at times, even chaos.

        I don’t know that my wife is ‘shy’ per se, she just wants to be treated for herself and not some caricature our culture has of DID. This article listed schizophrenia as one of the ‘worst’ impugned mental health issues. DID is right up there with it.

        My hope is that this book, if I can get it finished, will normalize mental health struggles from the family, spouse and significant other’s perspective. My wife and I have walked together through almost any extreme state imaginable, and we learned how to help her heal from all of them so that most are a distant memory from the past at this point in our journey. Yes, I’m often called to do more than I would have to for a spouse without these struggles, but I guess that’s part of being in a loving, lifetime relationship.
        Sam

        • Sam, you often come accross to me as a paragon of ACCEPTANCE. That is one of the most powerful ways a person can be that can heal another person.

          These days it seems to me that everyone is fighting and snapping and lecturing and bickering and belittling and attacking rather than accepting the exciting potential in each of our many differences. You seem to me to be a fond welcomer of unique differences. I like how you are an emissary for your beloved. It is easy to be caring, it is much more spiritually advanced to be a carer, no matter what, especially an accepting one. Oh, I know you will feel bound to tell me that it is a pleasure to do what you do since you do it from honour and love but in the world at present it seems to be a pleasure for millions to just pointlessly rant at each other rather than value the uniqueness of each other.

          I think quite a few people would say they feel just a bit jealous that you have such a lovely arrangement with your wife. In your togetherness is a hope that all the lonely unloved people can find someone who cares for them as profoundly as you care for your dear one.

  5. Looks like absolute proof that “stigma” is caused by the diagnoses, or the person applying them, rather than some pre-existing social biases. If it matters which “diagnosis” you have, it’s clear the discrimination experienced is applied to the diagnosis itself and what we have been “taught” about these “diagnoses” by our wonderful Mental Health System and drug industry. In other words, no “diagnoses,” and the “stigma” doesn’t happen.

  6. I know I love to pointlessly rant. It’s what I live for now that my life is completely destroyed and I will never see any justice. I still don’t think anyone should be allowed to go on ad infinitum about someone else’s “severe mental illness.”

  7. “Fortunately, I realized almost immediately that I had safely lived with her for 20 years and she was unlikely to kill me in my sleep at that point if I hadn’t given her reason before then…”

    I don’t find this amusing, if it’s a joke. If it’s not a joke, it’s disturbing.
    No, shy people are not “the most marginalized and stigmatized.”

    I have carried a diagnosis for decades that in public perception is inextricably intertwined with criminal behavior including murder.

    It goes: Woman murders (or is accused of murdering) someone. Woman is put on trial. The prosecution hires an “expert” to testify that the woman has borderline personality disorder. Social media goes wild with another round of “all borderlines are worthless, devoid of empathy, scheming, lying, manipulative etc, deserve imprisonment or worse.” Then the media finds someone else to demonize and the whole process repeats.

    I may be bitter but at least I try to make sense.

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