The potential of continuum versus biogenetic beliefs in reducing stigmatization against persons with schizophrenia: An experimental study

Discrimination and Social Exclusion of People Experiencing Mental Disorders in Burkina Faso: A Socio-anthropological Study

Stigma has been pointed out as a barrier to mental healthcare in sub-Saharan Africa. Among the manifestations of stigma, the use of physical restraints is condemned as a form of violation of basic human rights. Research on this phenomenon is limited in West Africa and more particularly in Burkina Faso. This study explores the phenomenon of stigma of individuals experiencing mental disorders in Bobo-Dioulasso (Burkina Faso). As part of 8 months of socio-anthropological fieldwork, we interviewed 94 informants (7 focus groups and 25 individual interviews) to document exclusionary practices, their perceptions, and justifications. Exclusionary practices can be divided in five subgroups: ignoring, physically and sexually abusing, abandoning, banning, and restraining. Some practices were linked to a lack of financial and material resources, while others were justified by an inferior moral status. We observed differences in the type of exclusion experienced between men and women. Restrictive, abusive, and exclusionary measures are common in Bobo-Dioulasso. These practices can either be understood as part of families' adaptative strategies when dealing with chronic conditions, as part of security measures in the case of patients with aggressive behaviors, or as part of punitive measures when transgressions are committed. We conclude the article by addressing the tensions between local and global meanings of stigma.

Should we promote alcohol problems as a continuum? Implications for policy and practice

The highly heterogeneous nature of alcohol use and problems has presented significant challenges to those attempting to understand, treat or prevent what is commonly termed alcohol use disorder (AUD). However, any attempts to capture this complex phenomenon, including the various current criterion of AUD, come with a number of limitations. One particular limitation has been how alcohol problems are represented or understood in ways which do not capture the broad spectrum of alcohol use and harms and the many potential routes to prevention, treatment, and recovery. One possible response to this has been proposed as more explicitly framing or conceptualizing a continuum model of alcohol use and harms. In this commentary, we attempt to identify the key implications of a continuum model for policy and practice, examining the historical and current context of alcohol problem classifications and models. We argue a continuum model of alcohol use and problems holds a number of advantages for advancing public health goals, but also some potential limitations, both of which require further examination.

Exploring Continuum and Categorical Conceptualisations of Mental Health and Mental Illness on Australian Websites: A Systematic Review and Content Analysis

It is important to explore the types of conceptualisations and causes presented in online mental health promotion given the implications that these presentations may have on mental health stigma. This study systematically reviewed 92 Australian webpages focused on either mental health, mental illness, depression, or schizophrenia, to explore the types of conceptualisations and aetiologies presented. A minority of mental health and mental illness webpages (n = 8, 8.70%) explicitly presented continuum conceptualisations, with none providing explicit categorical conceptualisations. No depression or schizophrenia webpages presented explicit conceptualisations of any kind. All four webpage foci had a greater proportion of continuum than categorical conceptualisations. Moreover, both depression and schizophrenia webpages presented many mixed conceptualisations which included both continuum and categorical messaging. Most webpages mentioned biological and social causes equally across webpage foci. These findings suggest that Australian mental health websites predominantly present continuum conceptualisations of mental health and mental illness.

Continuum beliefs of mental illness: a systematic review of measures

PURPOSE

The continuum of mental health/illness has been subject to scientific debate for decades. While current research indicates that continuum belief interventions can reduce mental health stigma and improve treatment seeking in affected populations, no study has yet systematically examined measures of continuum beliefs.

METHODS

This preregistered systematic review summarizes measures of continuum beliefs. Following the PRISMA statement, three scientific databases (PubMed, PsycInfo and PsycArticles via EBSCOhost, Web of Science) are searched, instruments are described and discussed regarding their scope, and methodological quality.

RESULTS

Overall, 7351 records were identified, with 35 studies reporting relevant findings on 11 measures. Most studies examined general population samples and used vignette-based measures. Schizophrenia and depression were most commonly examined, few studies focused on dementia, ADHD, OCD, eating disorders, and problematic alcohol use, or compared continuum beliefs across disorders. Validity was very good for most measures, but reliability was rarely tested. Measures mostly assessed beliefs in the normality of mental health symptoms or the normality of persons with such symptoms but rarely nosological aspects (i.e., categorical v continuous conceptualization of mental disorders).

CONCLUSIONS

Current research provides psychometrically sound instruments to examine continuum beliefs for a variety of mental disorders. While studies suggest utility for general population samples and mental health professionals, more research is necessary to corroborate findings, for instance, regarding age (e.g., in adolescents), gender, or type of mental disorder. Future research should also compare self-report ratings, and vignette-based measures, include measures of nosological concepts to fully grasp the continuum concept of mental illness.

PREREGISTRATION

PROSPERO: CRD42019123606.

The effect of alcohol use disorder symptom and recovery narratives on problem-recognition: A randomized online trial

BACKGROUND

Low problem recognition is a barrier to seeking treatment for alcohol use disorder ("AUD"). Promoting continuum belief narratives, which conceptualize AUD as a spectrum, together with narratives that promote non-abstinence recovery may boost self-recognition of risky drinking. This experimental study examines the effect of dichotomous vs continuous symptom narratives and non-abstinence vs abstinence recovery narratives on self-recognition of risky drinking among students.

METHODS

N = 489 participants were randomized to one of four interventions combining a continuous vs dichotomous AUD symptom narrative with an abstinence vs moderated drinking AUD recovery narrative in a 2×2 design. Participants completed demographic and alcohol use (AUDIT-C) preintervention measures and postintervention measures assessing self-recognition of risky drinking and endorsement of continuum beliefs.

RESULTS

Moderate drinking recovery narratives resulted in higher endorsement of continuum beliefs (F (1, 485) = 16.27, p <.001, η2p =.032 90 % CI [0.01, 0.06]). Recognizing own risky drinking behavior was unaffected by the interventions. However, in a subgroup of participants without prior AUD experience who met AUDIT-C criteria for risky drinking, the combination of a continuous symptom narrative and moderated drinking recovery narrative resulted in higher problem recognition (F (1, 48) = 5.79, p =.020, η2p =.10, 90 % CI [0.01, 0.25]).

CONCLUSIONS

Exposure to moderated drinking recovery narratives may help develop an awareness in young adults that problematic alcohol use exists on a spectrum. Among those at increased risk for AUD, exposure to narratives that promote a continuous model of AUD and non-abstinence recovery may increase problem recognition.

Continuum beliefs and the perception of similarities and differences to a person with depression

OBJECTIVE

Both continuum beliefs (i.e., that mental disorder exists on a spectrum of normative behavior patterns) and the perception of similarities to a person with schizophrenia have shown mixed effects on reducing mental illness stigma. To our knowledge, this is the first study to address continuum beliefs and the perception of similarities to a person with depression in the context of depression-related stigma.

METHODS

This work is based on an online intervention study in an ethnically diverse sample recruited on Amazon MTurk including previously unanalyzed qualitive responses. Within this cross-sectional, mixed-methods online investigation (N = 304), we examined the relation of perceived similarities to continuum beliefs, social distance, and negative stereotypes in relation to a vignette about depression. A randomly assigned continuum beliefs intervention attempted to induce continuum beliefs about depression. An open-writing task asked participants to describe similarities and/or differences between themselves and the person depicted in the vignette.

RESULTS

The continuum beliefs intervention was associated to a greater number of perceived similarities to and fewer perceived differences from the target vignette. Moreover, perceived similarities were associated with increased continuum beliefs, less social distance, and less-negative stereotypes. Perceived differences from a person with depression were associated with increased social distance.

LIMITATIONS

Even though the continuum beliefs intervention did not significantly alter stigma measures directly, expressed continuum beliefs were associated to decreased mental illness stigma.

CONCLUSIONS

The findings emphasize that perceived similarities to an outgroup member (i.e., a person with depression) might augment the stigma-reducing mechanism of continuum beliefs.

The "alcoholic other": Harmful drinkers resist problem recognition to manage identity threat

OBJECTIVE

Harmful drinkers represent an important Alcohol Use Disorder (AUD) group in public health terms, accounting for significant health and social costs. However, harmful drinkers are characterized by low problem recognition; they tend to construct their drinking identity as positive and problem-free, actively setting themselves apart from the stigmatised 'alcoholic other'. As such, harmful drinkers rarely engage in treatment and represent an important opportunity for lower threshold interventions and self-change. The present study sought to explore AUD problem framing and stigma effects on problem recognition.

METHODS

Harmful drinkers without perceived addiction experience recruited online (n = 244, 54% male, 46% female, 96% British) were randomised to one of six conditions comprising beliefs about alcohol problems (control, continuum, binary disease model) and stigma (stigma, non-stigma), and completed measures relating to problem recognition.

RESULTS

As predicted, results found that harmful drinkers exposed to binary disease model beliefs and stigmatising language had significantly lower problem recognition than those in other conditions. However, no support was found for the prediction that continuum beliefs would be associated with higher problem recognition. Results suggest that the interaction of binary disease model beliefs and stigma prompted alcoholic label avoidance.

CONCLUSION

These findings suggest that problem framing has important consequences for harmful drinkers. Implications for behaviour change amongst harmful drinkers through mechanisms of problem framing and identity are discussed.

Effects of online continuum and categorical belief manipulations on schizophrenia stigma, help-seeking, and help-provision

Most research investigating the effect of continuum beliefs on stigma has used weak manipulations which may contribute to mixed findings within the experimental literature. There is also a lack of research into how continuum belief manipulations may impact help-seeking and help-provision. This study used an online manipulation of continuum and categorical beliefs about schizophrenia to examine the subsequent impacts on stigma, help-seeking, and help-provision. A total of 271 participants were randomised into either a continuum, categorical, or control condition. Participants received an informational video, a magazine article, and research highlights relevant to their condition. Prosocial support behaviour was assessed through a novel volunteering measure. The magnitude of change between pre-intervention and post-intervention measures of continuum and categorical beliefs was large. Continuum presentations reduced prognostic pessimism and negative stereotyping. Meanwhile, categorical presentations increased prognostic pessimism. Participants across conditions showed increased help-providing intentions after removing the highest scores to avoid ceiling effects. Fear and blame also decreased significantly across all conditions. There was no difference between conditions on our novel volunteer help-provision measure. Our findings have implications for anti-stigma programs and may help inform the design of future continuum belief manipulations.

Changing Attitudes Towards Voice Hearers: A Literature Review

Auditory verbal hallucinations, or voice hearing, is increasingly understood as a common experience. Despite this, voice hearers still experience a great deal of stigma, which can have serious negative impacts on the person's experience of their voices, and their recovery. Research has demonstrated that healthcare professionals may be a major source of the stigma surrounding voice hearing, with service-level implications for the development and delivery of evidence-based interventions. Therefore, reducing this stigma is a critical intervention target. The purpose of this narrative review is to examine evidence for interventions aimed at reducing stigma towards people who hear voices, in populations of healthcare professionals, students, and the general public. The available evidence supports the use of anti-stigma interventions based around direct contact with voice hearers and education about voice hearing. However, further research is necessary in this area to confirm these findings.

Continuum beliefs and mental illness stigma: a systematic review and meta-analysis of correlation and intervention studies

BACKGROUND

Promulgating a continuum model of mental health and mental illness has been proposed as a way to reduce stigma by decreasing notions of differentness. This systematic review and meta-analysis examines whether continuum beliefs are associated with lower stigma, and whether continuum interventions reduce stigma.

METHODS

Following a pre-defined protocol (PROSPERO: CRD42019123606), we searched three electronic databases (PubMed, Web of Science, and PsycINFO) yielding 6726 studies. After screening, we included 33 studies covering continuum beliefs, mental illness, and stigma. Of these, 13 studies were included in meta-analysis.

RESULTS

Continuum beliefs are consistently associated with lower stigma. Interventions were effective at manipulating continuum beliefs but differ in their effects on stigmatising attitudes.

CONCLUSIONS

We discuss whether and to what extent attitudes towards people with mental illness can be improved by providing information on a mental health-mental illness continuum. It appeared to be relevant whether interventions promoted a feeling of 'us' and a process of identification with the person with mental illness. We discuss implications for the design of future interventions.

A Call to Action. A Critical Review of Mental Health Related Anti-stigma Campaigns

Using a knowledge-attitudes-behavior practice (KABP) paradigm, professionals have focused on educating the public in biomedical explanations of mental illness. Especially in high-income countries, it is now common for education-based campaigns to also include some form of social contact and to be tailored to key groups. However, and despite over 20 years of high-profile national campaigns (e.g., Time to Change in England; Beyond Blue in Australia), examinations suggest that the public continue to Other those with experiences of mental ill-health. Furthermore, evaluations of anti-stigma programs are found to have weak- to no significant long-term effects, and serious concerns have been raised over their possible unintended consequences. Accordingly, this article critically re-engages with the literature. We evidence that there have been systematic issues in problem conceptualization. Namely, the KABP paradigm does not respond to the multiple forms of knowledge embodied in every life, often outside conscious awareness. Furthermore, we highlight how a singular focus on addressing the public's perceived deficits in professionalized forms of knowledge has sustained public practices which divide between "us" and "them." In addition, we show that practitioners have not fully appreciated the social processes which Other individuals with experiences of mental illness, nor how these processes motivate the public to maintain distance from those perceived to embody this devalued form of social identity. Lastly, we suggest methodological tools which would allow public health professionals to fully explore these identity-related social processes. Whilst some readers may be frustrated by the lack of clear solutions provided in this paper, given the serious unintended consequences of anti-stigma campaigns, we caution against making simplified statements on how to correct public health campaigns. Instead, this review should be seen as a call to action. We hope that by fully exploring these processes, we can develop new interventions rooted in the ways the public make sense of mental health and illness.

Public Continuum Beliefs for Different Levels of Depression Severity

Introduction: The notion that depression is a disorder that moves along a continuum is well-established. Similarly, the belief in the continuity of mental illness is considered an important element in the stigma process. Against this background, it is the aim of this study to examine whether public continuum beliefs vary with the severity of depressive symptoms. Methods: Analyses were based on computer-assisted telephone interviews (CATIs) conducted in winter 2019/2020 in Germany (N = 1,009, response rate 46.8%). Using three vignettes representing mild, moderate, and severe depressive symptoms, beliefs regarding the continuity of symptoms, specifically a fundamental difference, were assessed with seven items. Sociodemographic characteristics and own experiences with depression (affliction and contact) were introduced as covariates. Results: Significant differences between the three groups of severity were found for the majority of the items measuring continuum beliefs or perceived fundamental difference. However, only few items showed a linear trend indicating a parallel between symptom severity and beliefs. Multivariate regression models showed that a moderate degree of depression was positively associated with stronger continuum beliefs but also with greater perceived difference compared to the mild degree, while no significant associations emerged for the severe vignette. Limitations: Although a comparison of our sample with official statistics supports the external validity, we cannot rule out a selection bias. It is arguable in how far short case vignettes convey a holistic picture of a person affected by depressive symptoms. Conclusion: Our results do not indicate a parallel between symptom severity and public continuum beliefs.

The beliefs of non-psychiatric doctors about the causes, treatments, and prognosis of schizophrenia

OBJECTIVES

To examine the causal beliefs about schizophrenia of non-psychiatric doctors and whether differential belief in biogenetic vs. psychosocial causes influences doctors' views about treatments and prognosis.

DESIGN AND METHODS

Three hundred and five non-psychiatric doctors working in outpatient community centres completed the 'Opinions on mental disorders Questionnaire' after reading a clinical description of people with schizophrenia.

RESULTS

The factors most frequently reported as causes of schizophrenia were heredity (65.2%) and use of street drugs (54.1%). Seventy-five per cent of participants endorsed both one or more biological causal factors and one or more psychosocial causal factors. Of the 264 participants who expressed their opinion about the most important cause of schizophrenia, 53.8% indicated a biogenetic cause. Fifty-two per cent of respondents thought it 'completely true' that drugs are useful in schizophrenia, and 33.9% thought it 'completely true' that people with schizophrenia must take drugs all their life. Participants stating that the most important cause was biogenetic more frequently recommended a psychiatrist and less frequently a psychologist. Compared to doctors who indicated a psychosocial cause as the most important one, those who indicated a biogenetic cause were more sceptical about recovery, more confident in the usefulness of drugs, and more convinced of the need of lifelong pharmacological treatments in schizophrenia.

CONCLUSIONS

These findings suggest the need to provide some doctors with training on the multiple, interacting causes of schizophrenia and the efficacy of the broad range of available treatments. The education of health professionals regarding stigma and its effects on clinical practice is also needed.

PRACTITIONER POINTS

Viewing schizophrenia as mainly due to a biological cause is associated with greater confidence in the usefulness of drugs, higher belief in the need for lifelong pharmacological treatments, and greater prognostic pessimism. Belief in a biologically oriented model of schizophrenia may lead doctors to underestimate the value of psychologists. Prognostic pessimism among doctors may negatively influence clinical decisions, the information doctors provide to their clients, and clients' own beliefs about their chances of recovery. Belief in the need for lifelong pharmacological treatments in schizophrenia may lead doctors to resist drug withdrawal in case of severe side effects.

Continuum beliefs are associated with higher problem recognition than binary beliefs among harmful drinkers without addiction experience

Low problem recognition may be an important barrier to opportunities for self-change or help-seeking in harmful drinkers. Little is known about how the beliefs harmful drinkers hold about the nature and causes of alcohol problems affect problem recognition and subsequent behaviour change processes. Participants (n = 597) recruited online were randomised to one of two conditions designed to promote beliefs according to (a) a continuum model of alcohol problems or (b) a binary disease model, or (c) a control condition. Participants completed measures of alcohol problem beliefs, problem recognition and other indices including the Alcohol Use Disorder Identification Test (AUDIT), addiction beliefs, addiction experience and demographics. Results showed that harmful drinkers without addiction experience exposed to the continuum condition had significantly higher problem recognition than those in binary disease model or control conditions. Continuum beliefs appear to offer self-evaluative benefits for harmful drinkers with low alcohol problem recognition, thus potentially facilitating help-seeking or self-change regarding alcohol use. Further research to understand the mechanisms by which continuum beliefs may promote more accurate drinking self-evaluation and its potential for behaviour change is warranted. The role of continuum beliefs may have important consequences for alcohol-related messaging and interventions seeking to promote self-change or help-seeking.

How continuum beliefs can reduce stigma of schizophrenia: The role of perceived similarities

Growing evidence has shown continuum beliefs as a promising tool to reduce psychiatric stigma in the general population, but data still lack regarding mechanisms underlying this effect. This study aims at testing the hypothesis that continuum beliefs affect public stigma and self-stigma by increasing perceived similarities between oneself and people with schizophrenia. Perceiving such similarities may reduce public stigma and increase self-stigma in the general population. The current study was preregistered on OSF. Data were collected via an on-line survey (N = 565). Participants were randomly assigned to one of the three experimental conditions. Continuum beliefs were induced with short videos supporting either a continuum viewpoint of schizophrenia, a categorial viewpoint of schizophrenia, or a neutral video. A scale of Perceived similarities between oneself and people with schizophrenia was administered. Public stigma was measured with an Essentialism scale and Self-stigma with a scale of self-stereotype association. Mediation analyses showed that the effects of categorial and continuum beliefs on essentialism and self-stereotype association were mediated by perceived similarities. Our results suggest that continuum beliefs about schizophrenia act as a recategorization mechanism, by enhancing perceived similarities with the stereotyped group.

ADHD, stigma and continuum beliefs: A population survey on public attitudes towards children and adults with attention deficit hyperactivity disorder

ADHD is a mental illness of high epidemiological and clinical importance, embedded in a complex socio-cultural context. We estimated the prevalence of attitudes related to ADHD in a representative population survey in Germany (n = 1008) after presenting an unlabelled vignette of a child or an adult with ADHD. Relations of personal experience, interpersonal contact and continuum beliefs with emotions and social distance were calculated using path models. About two-thirds of the German public indicated they believe in a continuum of ADHD symptoms, and half stated that they know somebody among family or close friends with a comparable problem. About one-quarter of respondents felt annoyed by the depicted person. While an adult with ADHD was most frequently accepted as a work colleague or neighbor, about one-quarter of the German general population rejected renting a room or giving a job recommendation. Personal Experience (both vignettes) and contact (adult vignette) were related to a higher belief in a continuum of symptoms, while explanation of variance was low. A belief in a continuum of symptoms was related to more pro-social reactions and less social distance. This study indicates that emphasizing aspects of a continuum of symptoms should be considered within the disorder model of ADHD.

The stigma of mental illness: Testing for the implicit bias in diagnostic labels

Several models that attempt to explain stigmatization of people with mental illness emphasize the relevance of social categorization. However, research on illness-based social categories has been limited to explicit self-report measures. In this study, we explored whether implicit social categorization based on mental illness labels can be assessed with the "Who-Said-What" (WSW)-paradigm. In this paradigm, participants have to allocate a large number of statements to individuals who belong to different social groups (e.g., mentally ill vs. healthy). Due to the amount of statements, errors in allocation are to be expected. A disproportionate amount of erroneous allocation to individuals within a social group is interpreted to indicate implicit social categorization. In three studies, we (1) pilot-tested a WSW-paradigm for mental illness categorization (n = 24), (2) replicated these findings in an independent, larger sample (n = 85), and (3) aimed to rule out alternative explanations for the implicit categorization effects with a modified WSW-task and novel stimulus material (n = 137). We found consistent implicit categorization effects with overall medium to large effect sizes (range: 0.41 ≤ d ≤ 1.01). Implicit components of mental illness based social categorization can be assessed with the WSW-paradigm. Future research needs to explore the interrelations of implicit categorization, implicit vs. explicit stigmatization and discriminating behavior.

Decreasing Stigmatization: Reducing the Discrepancy Between "Us" and "Them". An Intervention for Mental Health Care Professionals

Objective: Stigmatization has negative consequences for people with mental health disorder diagnosis. Studies indicate that professionals have stigmatizing attitudes and behavior towards clients. Continuum beliefs are associated with less stigmatizing attitudes. The effect of a workshop to diminish stigmatizing attitudes and to enhance continuum beliefs is examined. Method: A total of 202 mental health professionals from (Functional) Assertive Community Treatment [(F)ACT] teams were randomly assigned to a workshop or a waiting list control group. Stigmatizing attitudes and continuum beliefs were assessed in both conditions at baseline and follow-up. Results: Compared to baseline, the workshop group showed an increase on continuum beliefs. However, there was no effect of the intervention on stigmatizing attitudes. Contrary to the expectations, stigmatizing attitudes increased in the waiting list condition. Conclusion: Communicating the continuity aspect can be valuable in decreasing the "us and them" discrepancy between professionals and people with mental health disorders. Further research on continuum beliefs is needed.

On continuum beliefs and psychiatric stigma: Similarity to a person with schizophrenia can feel too close for comfort

Continuum belief interventions that blur boundaries between "normal" individuals and individuals with psychiatric problems have shown promise in reducing psychiatric stigma. Interventions to date have afforded participants considerable psychological distance from individuals with mental illness. An intervention that compels psychological closeness to individuals with mental illness may lead to increased anxiety/threat and an attenuated intervention effect on stigma. In a randomized experiment, one hundred thirty-five participants listened to a bogus interview involving an ostensible person with schizophrenia who shared numerous characteristics in common with participants. In the interview, the target person (1) did not verbally broach issues of similarity to "normal" people, (2) endorsed a continuum view, or (3) endorsed a categorical view. Participants then read a bogus research article on schizophrenia that (1) was agnostic with respect to the continuum/categorical distinction, (2) attested to a continuum view, or (3) attested to a categorical view. Correlational analyses demonstrated that greater endorsement of continuum beliefs predicted less stigma. Experimental analyses demonstrated that the continuum intervention had no effect on stigma. The continuum intervention increased participants' feelings of anxiety/threat, measured via self-report and a lexical decision task. These findings might usefully inform the design of stigma reduction programming centered on continuum beliefs.

Interventions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis

This review evaluates the evidence on what interventions are effective in reducing public stigma towards people with severe mental illness, defined as schizophrenia, psychosis or bipolar disorder. We included 62 randomised controlled trials of contact interventions, educational interventions, mixed contact and education, family psychoeducation programs, and hallucination simulations. Contact interventions led to small-to-medium reductions in stigmatising attitudes (d = 0.39, 95% CI: 0.22 to 0.55) and desire for social distance (d = 0.59, 95% CI: 0.37 to 0.80) post-intervention, but these were reduced after adjusting for publication bias (d = 0.24 and d = 0.40, respectively). Effects did not vary by type or length of contact. Effects at follow-up were smaller and not significant. Education interventions led to small-to-medium reductions in stigmatising attitudes (d = 0.30, 95% CI: 0.14 to 0.47) and desire for social distance (d = 0.27, 95% CI: 0.08 to 0.46) post-intervention. Small improvements in social distance persisted up to 6 months later (d = 0.27, 95% CI: 0.05 to 0.49), but not attitudes (d = 0.03, 95% CI: -0.12 to 0.18). The combination of contact and education showed similar effects to those that presented either intervention alone, and head-to-head comparisons did not show a clear advantage for either kind of intervention. Family psychoeducation programs showed reductions in stigma post-intervention (d = 0.41, 95% CI: 0.11 to 0.70). The effectiveness of hallucination simulations was mixed. In conclusion, contact interventions and educational interventions have small-to-medium immediate effects upon stigma, but further research is required to investigate how to sustain benefits in the longer-term, and to understand the active ingredients of interventions to maximise their effectiveness.

Dysfunction by Disclosure? Stereotype Threat as a Source of Secondary Neurocognitive Malperformance in Obsessive-Compulsive Disorder

OBJECTIVES

There is mixed evidence regarding whether patients with obsessive-compulsive disorder (OCD) display substantial neurocognitive deficits. Several studies implicate poor motivation, comorbid disorders, or distraction due to obsessive thoughts as potential causes of secondary malperformance. The present study examined the impact of stereotype threat (i.e., confrontation with a negative stereotype may impair performance) on neuropsychological functioning in individuals with OCD. We hypothesized that a stereotype threat cue emphasizing neurocognitive deficits in OCD (as is often conveyed in disclosure and consent documents that inform patients about the purpose of a study) would compromise patients' test performance relative to a control group who did not receive such cue.

METHODS

Fifty participants with either a verified or a likely diagnosis of OCD were recruited online and randomly assigned to either an experimental condition aimed to elicit stereotype threat or a control condition. Both groups underwent (objective) memory and attention (Go/NoGo task) assessments and completed questionnaires capturing psychopathology, cognitive complaints, and self-stigma.

RESULTS

As hypothesized, patients in the stereotype threat condition performed worse on the Go/NoGo task. Groups did not differ on any other measures.

CONCLUSIONS

Stereotype threat negatively impacted neuropsychological performance on an attention task. The threat cue was perhaps too weak or the stereotype threat was already internalized by the patients and "saturated" at baseline so that no effect emerged on the other measures. Implications for clinical trials are discussed. (JINS, 2018, 24, 584-592).

Do continuum beliefs reduce schizophrenia stigma? Effects of a laboratory intervention on behavioral and self-reported stigma

BACKGROUND AND OBJECTIVES

Correlational research shows that belief in a continuum of psychiatric problems predicts decreased public stigma. However, the correlational findings fail to inform the stigma reduction prospects of manipulating continuum beliefs. All extant experimental work has been executed online. This study examined effects of a laboratory-based continuum intervention on behavioral and self-report measures of psychiatric stigma.

METHODS

Sixty-nine undergraduates believed that they would meet a man with schizophrenia. They then read a bogus scientific article that attested to a categorical view of schizophrenia, a continuum view, or that merely described schizophrenia. Some participants then completed a task that required reflection on their differences from (categorical group) or similarities to (continuum group) the man with schizophrenia. Participants eventually moved to an adjacent room and sat in one of several seats that varied in their proximity to a seat ostensibly occupied by the man with schizophrenia.

RESULTS

The continuum intervention decreased self-reported social distance and the categorical intervention increased endorsement of damaging stereotypes. Seat selection was unaffected by our manipulation, but we obtained evidence of significant links to validated stigma measures.

LIMITATIONS

Our sample was small, and our behavioral stigma measure could be modified to maximize variability in participants' seat selection.

CONCLUSIONS

The study offers modest support of the stigma reduction effect of continuum belief intervention. It offers new evidence of the pernicious consequences of interventions that inflate perceptions of the "otherness" of individuals with psychiatric problems. Finally, it shines new light on stigma-related behavior measurable in the laboratory.

“Just Like Someone Without Mental Illness, Only More So”: Normalizing Beliefs and their Buffering Effects on Psychiatric Symptoms

Self-stigma leads sufferers of psychiatric conditions to experience reduced self-efficacy and self-esteem as well as avoid treatment, employment, and social opportunities. There is a dearth of research on the mechanisms underlying individuals' ability to resist stigmatizing beliefs; furthermore, research has revealed limitations in current popular approaches to de-stigmatization, such as emphasizing the biological and genetic characteristics of symptoms. We propose normalization—the understanding of psychiatric phenomena as varying degrees of normative, understandable, and common experiences—as a cross-diagnostic protective factor against self-stigma. We recruited a sample of 137 online study participants to pilot an assessment of normalization, predicting that normalizing beliefs about psychiatric symptoms would positively influence quality of life, especially for those who report personal experience of symptoms. We found evidence for this prediction: belief that psychiatric symptoms were relatively common, buffered the negative effect of people's own psychiatric symptoms on quality of life. Cross-diagnostic symptom normalization may function as a protective factor against the negative effects of psychiatric symptoms and associated stigma.

Continuum beliefs and stigmatising beliefs about mental illness: results from an Asian community survey

OBJECTIVES

To establish the prevalence and correlates of continuum beliefs for five mental illnesses in a multiethnic population and to explore its association with stigma.

DESIGN

A community-based, cross-sectional study.

SETTING

A national study in a multiethnic Asian country.

PARTICIPANTS

A comprehensive study of 3006 Singapore residents (Singapore citizens and permanent residents) aged 18-65 years who were living in Singapore at the time of the survey.

OUTCOME MEASURES

Parameters assessed included belief in a continuum of symptom experience, stigma dimensions and causal beliefs in mental illness. Statistical analyses included descriptive statistics and multiple linear regression (MLR).

RESULTS

About half of the population indicated agreement with a continuum of symptoms for depression (57.9%) and dementia (46.8%), whereas only about one in three respondents agreed with it for alcohol abuse (35.6%), schizophrenia (32.7%) and obsessive-compulsive disorder (OCD) (36.8%). MLR analyses revealed that students (β=0.28; 95% CI 0.05 to 0.50; p=0.018) and those who were unemployed (β=0.60; 95% CI 0.26 to 0.95; p=0.001) (vs employed) as well as those who had previous contact with people with mental illness (β = 0.31; 95% CI 0.18 to 0.45; p<0.001) and believed stress, family arguments, difficulties at work or financial difficulties to be a cause for mental illness (β=0.43; 95% CI 0.13 to 0.73; p=0.005) were associated with a higher belief in a continuum of symptom experience. Continuum beliefs were related to lower desire for social distance in alcohol abuse, OCD and schizophrenia; however, they were associated with higher scores on 'weak-not-sick' stigma dimension in dementia and schizophrenia.

CONCLUSIONS

Perceiving that a person with a mental illness is similar to themselves may reduce social distancing by the public. Thus, the approach may lend itself well to public education aimed at reducing stigma.

Continuum beliefs in the stigma process regarding persons with schizophrenia and depression: results of path analyses

Background

Individuals with mental illness often experience stigmatization and encounter stereotypes such as being dangerous or unpredictable. To further improve measures against psychiatric stigma, it is of importance to understand its components. In this study, we attend to the step of separation between “us” and “them” in the stigma process as conceptualized by Link and Phelan. In using the belief in continuity of mental illness symptoms as a proxy for separation, we explore its associations with stereotypes, emotional responses and desire for social distance in the stigma process.

Methods

Analyses are based on a representative survey in Germany. Vignettes with symptoms suggestive of schizophrenia (n = 1,338) or depression (n = 1,316) were presented to the respondents, followed by questions on continuum belief, stereotypes, emotional reactions and desire for social distance. To examine the relationship between these items, path models were computed.

Results

Respondents who endorsed the continuum belief tended to show greater prosocial reactions (schizophrenia: 0.07; p < 0.001, depression: 0.09; p < 0.001) and less desire for social distance (schizophrenia: −0.13; p < 0.001, depression: −0.14; p < 0.001) toward a person with mental illness. In both cases, agreement with the stereotypes of unpredictability and dangerousness was positively associated with feelings of anger and fear as well as desire for social distance. There were no statistically significant relations between stereotypes and continuum beliefs.

Discussion

Assumptions regarding continuum beliefs in the stigma process were only partially confirmed. However, there were associations of continuum beliefs with less stigmatizing attitudes toward persons affected by either schizophrenia or depression. Including information on continuity of symptoms, and thus oppose perceived separation, could prove helpful in future anti-stigma campaigns.

Continuum beliefs about psychotic symptoms are a valid, unidimensional construct: Construction and validation of a revised continuum beliefs questionnaire

Growing evidence supports a continuum model of psychosis, with mild psychotic symptoms being frequently experienced by the general population. Moreover, believing in the continuum model correlates with less stigmatization of schizophrenia. This study explores whether continuum beliefs are a valid construct and develops a continuum beliefs scale. First, expert-generated items were reduced to a candidate scale (study 1, n=95). One-dimensionality was tested using confirmatory factor analysis (study 2, n=363). Convergent validity was tested with a previous continuum beliefs scale, essentialist beliefs, and stigmatization (study 2), while self-reported psychotic experiences (i.e. frequency and conviction) served to test discriminant validity (study 3, n=229). A nine item questionnaire that assesses continuum beliefs about schizophrenia symptoms showed acceptable to good psychometric values, high correlations with a previous continuum beliefs scale and small correlations with essentialist beliefs, stereotypes, and desired social distance. No correlations with psychotic experiences were found. Thus, continuum beliefs can be considered a valid construct. The construed CBQ-R asks about symptoms rather than the abstract category "schizophrenia", which may increase understandability of the scale. Validation confirms previous studies and highlights the difference between continuum beliefs and personal psychotic experiences.