The impact of self-stigma on self-esteem among persons with different mental disorders

Barriers to using physical exercise as an intervention within inpatient mental health settings: A systematic review

Service providers find it difficult to implement Physical Exercise (PE) strategies in routine care within inpatient mental health settings even though they perceive it to be an effective therapy, with a robust evidence base. Identifying barriers that exist can assist with the development of future interventions and support PE services being introduced into mental health inpatient settings. The aim of this systematic review was to synthesise the evidence on the barriers or perceived barriers that exist amongst service users and providers when incorporating PE as an intervention within inpatient mental health settings. Using a narrative synthesis approach, four main themes were identified: (i) Barriers relating to service users' mental and physical health, (ii) Factors relating to service providers, (iii) Environmental factors and (iv) Cultural factors. Both service users and providers need more knowledge on implementing PE in inpatient mental health settings. Tailored programmes for service users are warranted, with specialist roles for staff developed.

Stigma and self-esteem in facial burn patients: A correlation study

BACKGROUND

A considerable number of burn patients have greater psychological stress due to the special trauma site. In clinical practice, it is found that medical staff pay more attention to the rehabilitation of physical function, while the mental health status of patients is greatly neglected. In contact with patients, we found that attention should be paid to the levels of stigma and self-esteem. However, there are few studies on stigma and self-esteem in patients with facial burns. Therefore, this study aimed to describe the stigma and self-esteem levels of facial burns, investigate the relationship between these two variables, and explore the influencing factors of stigma in patients with facial burns, in order to provide evidence for follow-up interventions to improve this population.

METHODS

From August 2020 to June 2021, we recruited patients with facial burns who met the inclusion criteria in one burn specialist clinic and three burn units of a tertiary A hospital in Guangzhou, China. The survey tools of this study include sociodemographic and disease-related information questionnaires, the Chinese version of the Social Impact Scale, and the self-esteem scale (these scales were validated). SPSS 25.0 software was used for data analysis through t test, analysis of variance, correlation analysis, multiple linear regression method for data statistics.

RESULTS

The total stigma score of facial burn patients was (58.01 ± 7.57), which was at a medium level; the self-esteem score was (19.72 ± 2.43), which was at a low level. Correlation analysis showed that there was a positive correlation between the self-esteem score and the total score of stigma (r = 0.286, P < 0.01). The family per capita monthly income, education level, way of medical expenses expenditure, and self-esteem of facial burn patients were the influencing factors of their stigma, and these factors explained 33.7% of the variation in stigma (F=8.659, P＜0.01).

CONCLUSIONS

Patients with facial burns have low levels of stigma and self-esteem, which requires our efforts. In particular, there is a positive correlation between stigma and self-esteem, and self-esteem is an independent risk factor affecting stigma. Our findings suggest that interventions aimed at enhancing self-esteem have the potential to positively impact the reduction of stigma in this patient population.

Time perspective and self-stigma in schizophrenia

BACKGROUND

Time perspective (TP) offers a new understanding of human personality, postulating that there are individual differences in how our mind assigns our experiences to different time categories. This concept may shed new light on the role of personality traits in shaping vulnerability to the internalized stigma.

AIM

In this paper we propose a novel approach to clarifying the underpinning of self-stigma by empirically exploring its links with TP.

METHOD

We conducted a cross-sectional study among 86 patients with ICD-10 diagnoses of paranoid schizophrenia to validate the predictive role of TP for self-stigma. We used the Zimbardo Time Perspective Inventory (ZTPI), Internalized Stigma of Mental Illness scale (ISMI) and Brief Psychiatric Rating Scale (BPRS).

RESULTS

We found significant positive correlations of self-stigma with Past-Negative, Future-Negative and Present-Fatalistic TP categories and negative correlation with the Future-Positive category. The hierarchical regression analyses revealed that two TP categories and Deviation from the Balanced Time Perspective (DBTP) are significant predictors of self-stigma over and above sociodemographic and clinical control variables. Conclusion. The results of the study confirm the hypothesis that TP opens new possibilities to understand proneness or resistance to self-stigmatization, and this may provide a basis for novel approaches to anti-self-stigma interventions.

Internalized stigma and self-stigma in people diagnosed with a mental disorder. One concept or two? A scoping review

BACKGROUND

In the literature on stigma, authors often use self-stigma or internalized stigma interchangeably to refer to this type of stigma. This results in a lack of conceptual clarity with negative repercussions for measurement and intervention.

AIMS

To identify how internalized stigma and self-stigma are conceptualized in people diagnosed with a mental disorder and establish similarities and differences between both concepts.

METHOD

A scoping review was conducted. Thirty-five studies that conceptualized internalized stigma or self-stigma were selected.

RESULTS

It was identified that the concepts are defined from nine components, and there are more conceptualizations that have points in common than those that consider some component of their own. To gain conceptual clarity, the use of the term internalized stigma is recommended, being a process made up of stages: acceptance of stereotypes and prejudices by people with mental disorders and their subsequent internalization. The latter leads to negative consequences for those affected, which can be understood as the personal impact of this process, which has a crucial socio-cultural component. Lines of research are proposed to provide solidity to studies on this type of stigma.

CONCLUSIONS

The term internalized stigma should be used when referring to the type of stigma that includes acceptance, internalization and personal impact for the subjects of the stigma. In contrast, self-stigma should be reserved to refer to stigma that is directed toward the 'self' and includes subtypes of stigma.

The effectiveness of anti-stigma interventions for reducing mental health stigma in young people: A systematic review and meta-analysis

Experiencing mental health stigma during adolescence can exacerbate mental health conditions, reduce quality of life and inhibit young people's help-seeking for their mental health needs. For young people, education and contact have most often been viewed as suitable approaches for stigma reduction. However, evidence on the effectiveness of these anti-stigma interventions has not been consistent. This systematic review evaluated the effectiveness of interventions to reduce mental health stigma among youth aged 10-19 years. The review followed Cochrane and PRISMA guidelines. Eight databases were searched: PubMed, PsycINFO, MEDLINE, Web of Science, Scopus, EMBASE, British Education Index and CNKI. Hand searching from included studies was also conducted. Randomised controlled trials and experimental designs that included randomised allocation to interventions and control groups were included in the review. Narrative synthesis was employed to analyse the results. A meta-analysis was conducted to determine the effectiveness of included interventions. Twenty-two studies were included in the review. Eight studies reported positive effects, 11 studies found mixed effects and 3 studies reported no effect on indicators of mental health stigma among youth. Seven of the effective studies were education-based. Eleven studies were suitable for meta-analysis, and the multivariate meta-analytic model indicated a small, significant effect at post-intervention (d = .21, p < .001), but not at follow-up (d = .069, p = .347). Interventions to reduce stigma associated with mental health conditions showed small, short-term effects in young people. Education-based interventions showed relatively more significant effects than other types of interventions.

Narrative enhancement and cognitive therapy for perceived stigma of chronic schizophrenia: A multicenter randomized controlled trial study

This study explored the effects of NECT on self-stigma among people with schizophrenia. Eighty-six participants were recruited and assigned to two groups. The NECT group received 20-session group meetings, while the control group received routine care. Self-stigma was measured by Internalized Stigma of Mental Illness Scale (ISMIS) and Discrimination and Stigma Scale (DISC). Generalized estimating equations were employed to explore the intervention's effectiveness. The NECT group showed a significant reduction in ISMIS total scores after 20 sessions and Stopping Self subscale scores of DISC decreased over time. The intervention is effective for improving self-stigma in people with schizophrenia.

Discrimination, stigma and mental health: what's next?

Stigma and discrimination are a major ongoing problem in the field of mental health as these impact on patient outcomes, access to and acceptability of therapeutic interventions, their quality of life, general wellbeing, social inclusion and opportunities. Social stereotypes, culture and prejudices all contribute to continuing discrimination in mental health. Different settings where people function may also be sources of discrimination such as work and educational environments. The lack of knowledge and understanding of mental health/illness by individuals, their families, carers and policymakers as well as the social media reporting also impact on social attitudes to discrimination. It has been also described a relevant impact of stigma among specific social minorities reporting poor mental health such as elderly people, youths, sexual variants, persons with disability. Educational programs, raising awareness trainings and proper public policies may be developed in order to reduce stigma at social level with favourable outcomes for people with mental illness.

Self-stigma in schizophrenia: a systematic review and meta-analysis of 37 studies from 25 high- and low-to-middle income countries

In schizophrenia, it is currently thought that stigma experience is increased by psychotic and depressive symptomatology, exposure to stigma at the workplace, and that self-stigma levels vary across countries without knowing the factors explaining these variations. The aim of the present meta-analysis was to synthetize the data of observational studies comprehensively exploring multiple self-stigma dimensions and associated factors. A systematic literature search without language or time restrictions was conducted in Medline, Google Scholar, and Web of Science for studies, last 09/2021. Eligible studies that included ≥80% of patients diagnosed with schizophrenia-spectrum disorders and used a validated scale measuring self-stigma dimensions were meta-analysed using random-effects models, followed by subgroup and meta-regression analyses. Study registration: PROSPERO CRD42020185030. Overall, 37 studies (n = 7717) from 25 countries (5 continents) published between 2007 and 2020 were included, with 20 studies conducted in high-income countries. These studies used two scales with total scores ranging 1-4. The mean estimate of perceived stigma was 2.76 [95% confidence interval (CI) = 2.60-2.94], experienced stigma 2.29 [95% CI = 2.18, 2.41], alienation 2.40 [95% CI = 2.29, 2.52], stereotype endorsement 2.14 [95% CI = 2.03, 2.27], social withdrawal 2.28 [95% CI = 2.17, 2.39] and stigma resistance 2.53 [95% CI = 2.43, 2.63]). Self-stigma levels did not reduce over time. Living outside urban areas, low-income, singleness, unemployment, high antipsychotic dose and low functioning were associated with different stigma dimensions. Some stigma dimensions were lower in studies carried out in Europe compared to other regions. Most studies published since 2007 report that self-stigma is a particular concern for a specific subgroup of patients. This subgroup is characterized by unemployment, high antipsychotic dose and low functioning. We identified important other missing factors that should be explored to improve the effectiveness of public policies and personalized interventions to reduce self-stigma. Importantly, classical illness severity indices (psychotic severity, age at illness onset, illness duration) and sociodemographic variables (age, sex and education) were not associated with self-stigma, moderating previous findings.

The impact of stigma on engaged living and life satisfaction among people with mental illness in Hong Kong

PURPOSE

The present study aimed to investigate how the interpersonal (experienced discrimination) and intrapersonal (anticipated stigma and internalized stigma) manifestations of psychiatric stigma may affect engaged living and life satisfaction among people with mental illness. In this study, we developed and evaluated a conceptual model to clarify how experienced discrimination may lead to anticipated stigma and internalized stigma and thereby impede engaged living and reduce life satisfaction.

METHODS

A total of 205 Hong Kong Chinese people with mental illness completed standardized questionnaire measures of experienced discrimination, anticipated stigma, internalized stigma, engaged living, and life satisfaction. The associations among these variables were analyzed using path analyses and bootstrap analyses.

RESULTS

Path analyses showed that experienced discrimination was related to higher levels of anticipated stigma and internalized stigma, which were, in turn, linked to lesser engaged living and consequently lower life satisfaction. Bootstrap analyses further revealed that experienced discrimination had significant indirect effects on life satisfaction via anticipated stigma and engaged living and via internalized stigma and engaged living.

CONCLUSIONS

Theoretically, our study uncovers how the interpersonal and intrapersonal manifestations of psychiatric stigma may adversely affect engaged living and life satisfaction among people with mental illness. Practically, our study points to the importance of developing and implementing stigma-related interventions at societal and individual levels in order to enable people with mental illness to live fulfilling and satisfying lives.

Association between Self-Stigma and Suicide Risk in Individuals with Schizophrenia: Moderating Effects of Self-Esteem and Perceived Support from Friends

This cross-sectional study assessed the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk in individuals with schizophrenia. We included 300 participants (267 with schizophrenia and 33 with schizoaffective disorder). Suicide risk was assessed using items adopted from the suicide module of the Mini-International Neuropsychiatric Interview; self-stigma was assessed using the Self-Stigma Scale-Short; perceived support from friends was assessed using the Friend Adaptation, Partnership, Growth, Affection, and Resolve Index; and self-esteem was assessed using the Rosenberg Self-Esteem Scale. A moderation analysis was performed to examine the moderating effects of self-esteem and perceived support from friends on the association between self-stigma and suicide risk. The results indicated that self-stigma was positively associated with suicide risk after the effects of other factors were controlled for. Both perceived support from friends and self-esteem significantly reduced the magnitude of suicide risk in participants with self-stigma. Our findings highlight the value of interventions geared toward ameliorating self-stigma and enhancing self-esteem in order to reduce suicide risk in individuals with schizophrenia.

Gambling Disorder and Stigma: Opportunities for Treatment and Prevention

Purpose of Review

Gambling disorder is among the most stigmatized mental health problems. More research is needed to understand the mechanisms that underlie this stigma and the effects of stigma-reduction interventions. This paper reviews extant literature on the stigma of gambling disorder and highlights evidence from this research and the broader mental illness stigma literature to help advance research on the prevention and reduction of gambling-related stigma.

Recent Finding

The public stigma of gambling disorder includes stereotypes of affected individuals as “greedy” and “irresponsible,” beliefs that affected individuals are to blame for their problems, and desire to avoid social contact with affected individuals. Stigmatizing attitudes held by the public are often internalized by individuals with gambling disorder, which leads to problem concealment, reduced treatment-seeking, and decreased self-esteem. Women with gambling disorder, as well as those with more severe gambling problems and who perceive greater stigma by the public, are most vulnerable to self-stigma. There is evidence that certain beliefs may underlie the stigmatization of gambling disorder, including beliefs about its causes. Contact- and education-based interventions show efficacy for the reduction of mental illness-related stigma more broadly; additional research is needed to determine the efficacy of various stigma reduction strategies for gambling disorder specifically.

Summary

Gambling disorder is highly stigmatized relative to other mental health problems, in part because it is viewed as more likely to be caused by controllable factors. Interventions that emphasize the biopsychosocial etiology of gambling disorder may help to prevent and reduce the blame and stigmatization of affected individuals. Structural stigma within domains such as legislation, healthcare, and the gambling industry, interventions to reduce self-stigma, stigma among mental health professionals, and the influence of culture on stigma and its reduction are critical issues for future research.

The interplay between psychopathological symptoms: transdiagnostic cross-lagged panel network model

BACKGROUND

Recent paradigm shifts suggest that psychopathology manifests through dynamic interactions between individual symptoms.

AIMS

To investigate the longitudinal relationships between symptoms in a transdiagnostic sample of patients with psychiatric disorders.

METHOD

A two-wave, cross-lagged panel network model of 15 nodes representing symptoms of depression, (social) anxiety and attenuated psychotic symptoms was estimated, using baseline and 1-year follow-up data of 222 individuals with psychiatric disorders. Centrality indices were calculated to determine important predictors and outcomes.

RESULTS

Our results demonstrated that the strongest relationships in the network were between (a) more suicidal ideation predicting more negative self-view, and (b) autoregressive relationships of social anxiety symptoms positively reinforcing themselves. Negative self-view was the most predictable node in the network as it had the highest 'in-expected influence' centrality, and may be an important transdiagnostic outcome symptom.

CONCLUSIONS

The results give insight into longitudinal interactions between symptoms, which interact in ways that do not adhere to broader diagnostic categories. Our results suggest that self-view can also be a transdiagnostic outcome of psychopathology rather than just a predictor, as is normally posited, and may especially have an important relationship with suicidal ideation. Overall, our study demonstrates the dynamic complexity of psychopathology, and further supports the importance of investigating symptom interactions of different psychopathological dimensions over time and across disorders.

Internalized stigma among people with schizophrenia: Relationship with socio-demographic, clinical and medication-related features

BACKGROUND

People with schizophrenia are at high risk of suffering from stigma and internalizing it. Recently, a better understanding of the stigma process has shifted the attention from public stigma to self-stigma, which is deeply debilitating. This study aimed to assess factors associated to self-stigma by evaluating socio-demographic, clinical and treatment-related variables in a group of subjects diagnosed with schizophrenia and to identify predictors of high internalized stigma.

METHODS

Ninety-four inpatients accessing rehabilitative centers with a diagnosis of schizophrenia were included in this cross-sectional study. Measures included both patient-rated scales, assessing internalized stigma, attitude toward medications, side effects experience and subjective well-being, and clinician-rated scales, assessing schizophrenia symptoms and global clinical severity and antipsychotic-related side effects.

RESULTS

Twenty-one patients (22.3%) showed high internalized stigma while 73 (77.7%) did not. Patients experiencing more medication adverse effects and worse subjective well-being were more likely to suffer from internalized stigma according to a logistic regression analysis. Extrapyramidal, psychic and some autonomic reactions also emerged as individual predictors of self-stigma in a separate regression analysis.

CONCLUSIONS

Self-stigma and subjective medication side effects perception represent a relevant issue in patients' life and should be carefully taken into account in clinical practice.

Prevalence of Suicidal Behavior and Associated Clinical Correlates in Patients with Behavioral Addictions

Addictive disorders are characterized by severe consequences, including suicidal events, but most studies investigating the association between addiction and suicidal risk have focused on substance use disorders and gambling disorder at the expense of the rest of behavioral addictions. This study examined the prevalence and the associated clinical correlates of suicidal ideation and suicide attempts in a sample of patients with a diagnosis of behavioral addiction. The total sample consisted of 4404 individuals: 4103 of these patients with gambling disorder, 99 with gaming disorder, 44 with sex addiction, and 158 with buying–shopping disorder. All of them were assessed consecutively at a specialized hospital unit for the treatment of behavioral addictions. Participants attended two clinical interviews and completed self-reported questionnaires to explore clinical features of behavioral addictions, personality traits, psychopathological symptomatology, suicidal behavior, and sociodemographic variables. The highest prevalence of suicidal ideation was found in patients with gambling disorder (22.9%), followed by buying–shopping disorder (18.4%), sex addiction (18.2%), and gaming disorder (6.1%). The highest prevalence of suicide attempts was registered for sex addiction (9.1%), followed by buying–shopping disorder (7.6%), gambling disorder (6.7%), and gaming disorder (3.0%). Female gender and unemployment constituted two relevant sociodemographic factors associated with suicidal risk in gambling disorder, gaming disorder, and buying–shopping disorder. Lack of family support appeared as a relevant risk factor, except for gaming disorder. These results pointed out that suicide is a prevalent behavior in behavioral addictions, and clinicians and researchers need to pay particular attention to the specificities of each behavioral addiction when assessing suicidal risk.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency, Correlates, and Consequences

Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma-including from mental health providers-predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.

Internalization process of stigma of people with mental illness across cultures: A meta-analytic structural equation modeling approach

This meta-analytic study synthesized findings from 108 independent data sets across 22 cultures to investigate whether the stigma internalization model (the internalization of experienced stigma and perceived stigma to self-stigma) is associated with well-being and recovery of people with mental illness. We also examined the moderating role of collectivism in the internalization process. Results of the meta-analytic structural equation modeling suggested that self-stigma is a significant mediator in the relationships between experienced stigma and perceived stigma with well-being and recovery variables (indirect effects = 0.02 to -0.16). Experienced and perceived stigma had significant direct effects on well-being and recovery variables (Bs = 0.07 to -0.21, p < 0.05), suggesting that both external (e.g., public stigma) and internal (i.e., self-stigma) influences of stigma work concurrently to affect recovery and well-being of people with mental illness. The results of the mixed effect three-level meta-analytic models showed that collectivism significantly moderated the relationship between experienced and perceived stigma with self-stigma (Bs = 0.06 to 0.11, p < 0.05). This implied that the more collectivistic a culture is, the stronger the correlation between experienced and perceived stigma with self-stigma. Implications to stigma reduction approaches were discussed.

Development and validation of the self-stigma scale in people with diabetes

AIM

To develop and initially validate the Diabetes Self-Stigma Scale for assessing self-stigma in people with diabetes.

DESIGN

Scale development and evaluation.

METHODS

Participants were 399 patients with diabetes. In phase 1, initial items were generated based on the concept analysis of diabetes self-stigma. Moreover, content validity was established by diabetes experts. Phase 2 evaluated structural validity through item analysis, exploratory factor analysis and confirmatory factor analysis. Reliability was evaluated by examining stability and internal consistency.

RESULTS

The findings revealed that the self-stigma scale for patients with diabetes is a valid and reliable instrument. The Diabetes Self-Stigma Scale was confirmed with 16 items. It consists of four domains: comparative inability, social withdrawal, self-devaluation and apprehensive feeling. The scale developed in this study can measure self-stigma in diabetes patients and can be used as an intervention to reduce self-stigma.

Moderating Effect of Family Support on the Mediated Relation Between Negative Life Events and Antisocial Behavior Tendencies via Self-Esteem Among Chinese Adolescents

Adolescents are particularly prone to antisocial behavior. The promoting effect of negative life events on antisocial behavior has been well-documented. However, the internal influence mechanisms between negative life events and antisocial behavior tendencies in adolescents are still unknown. The aim of this study was to explore the mediation effect of self-esteem and the moderated mediation effect of family support between negative life events and antisocial behavior tendencies in 8,958 adolescents who were selected from three Chinese provinces. Robust maximum likelihood estimator (MLR) of a structural equation model (SEM) was applied to test the mediation model and the moderated mediation model. The results revealed that negative life events had a positive effect on antisocial behavior tendencies in adolescents, with a direct effect of 0.082 (95% CI: 0.052, 0.111) and an indirect effect via self-esteem of 0.168 (95% CI: 0.146, 0.191). Negative life events had a 67.20% effect on antisocial behavior tendencies, where self-esteem showed mediation. The indirect effect was 2.049-fold greater than the direct effect. Furthermore, the effect of latent interaction of subjective family support and negative life events on self-esteem was negatively significant (β = −0.018, p = 0.032, 95% CI: −0.035, −0.002). The indirect effect of negative life events was greater, where subjective family support was below 1 SD of the mean (conditional indirect effect = 0.227, 95% CI = 0.200, 0.255) than where it was above 1 SD of the mean (conditional indirect effect = 0.203, 95% CI = 0.177, 0.229). The moderated mediation effect index was −0.012, p = 0.033. Moderated mediation showed that the mediated path was less evident in the students who had greater subjective support from family. The results of the current study demonstrated the important role that self-esteem and subjective family support played in minimizing the adverse effect of negative life events on antisocial behavior development of adolescents. These findings have important implications for preventing antisocial behavior in adolescents by developing interventions aimed at enhancing their self-esteem and providing support-skill training to parents aimed at improving subjective family support of adolescents.

The impact of illness identity on recovery from severe mental illness: A review of the evidence

The "Illness Identity" model proposed that self-stigma impacts hope and self-esteem and subsequently leads to a cascade of negative effects on outcomes related to recovery among people diagnosed with severe mental illnesses. The purpose of the present review is to take stock of research support for the model. The citation index SCOPUS was reviewed for all papers published in peer-reviewed journals in English between 2010 and 2019 citing one of the initial 3 articles discussing the model: 111 studies met inclusion criteria and were reviewed. The most frequently tested, and supported, aspects of the model were relationships between self-stigma and self-esteem, hope, psychiatric symptoms and social relationships. Least frequently studied areas were relationships with suicide, avoidant coping, treatment adherence and vocational functioning, although they were supported in the majority of studies. The "insight paradox" was also tested in a relatively small number of studies, with mixed results. Findings were robust to geographic location of study, method, and subpopulation studied. Findings indicate that a large body of research has tested, and largely supported, the various components of the Illness Identity model, although some components need further investigation and there is a need for more comprehensive tests of the model.