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Continuum beliefs and stigmatizing attitudes towards persons with schizophrenia, depression and alcohol dependence

Psychiatry Research 2013, Volume 209, pages 665–669

Abstract

Separation is a central step in the process of stigmatizing persons with mental disorders. We examine whether belief in a continuum of symptoms from mental health to mental illness is associated with less stigmatizing attitudes. In a representative population survey in Germany (n=3642), using case-vignettes of persons suffering from schizophrenia, depression or alcohol dependence, we measured belief in a continuity of symptoms, emotional reactions and desire for social distance related to the person described in the vignette. While 42% of respondents agreed in symptom continuity for depression, this percentage was 26% for schizophrenia and 27% for alcohol dependence. Continuum beliefs were associated in general with more positive emotional reactions and less desire for social distance. This relationship was strongest for schizophrenia, followed by alcohol dependence. Continuum beliefs thus seem to be associated with less stigmatizing attitudes, particularly regarding schizophrenia and alcohol dependence. Educational information on the continuous nature of most psychopathological phenomena could usefully be integrated in anti-stigma messages.

Keywords: Symptom continuum, Social distance, Population survey, Stigma.

1. Introduction

The stigma of mental illness has been conceptualized as a process of several distinct, but interrelated steps ( Link and Phelan, 2001 ). Central to this process is a separation between “us” and “them”, leading to negative emotional reactions and resulting in discrimination and devaluation of the person. While the hypothetical first steps of the stigma process, labelling and stereotyping, and their relation to discrimination and devaluation have been examined in much detail (for example, Link et al., 1987 ;Link et al, 1989, Angermeyer and Matschinger, 1997, Corrigan, 1998, Martin et al, 2000, and Angermeyer and Matschinger, 2005), there is a surprising lack of studies focusing on perceived differentness and separation. This is deplorable, since theoretically, perceived differentness is a promising target for anti-stigma messages. An attitude opposed to it would be the perception that a person with mental illness is someone like us, and that to a certain degree his/her experiences resemble experiences of myself. This attitude is supported by epidemiological studies on the prevalence of psychiatric symptoms among the general population. For example, population studies provide evidence for a continuum of psychotic symptoms experience (Johns and van Os, 2001 and Van Os et al, 2010), experience of depressive symptoms ( Hankin et al., 2005 ) and experience of symptoms of alcohol dependence ( Saha et al., 2006 ). Thus many persons who do not fulfil criteria for a mental disorder nevertheless experience various psychiatric symptoms to different degrees. To incorporate this continuity of experiences in anti-stigma messages could be a promising way to reduce notions of differentness between those with and without mental illness, probably helping to combat the stigma of mental disorders.

However, so far it is not known whether belief in a continuum of mental illness symptoms is in fact associated with more tolerant attitudes towards persons with mental illness. Furthermore, it is unknown how continuum beliefs affect stigma in different mental disorders. Any potential effect of continuity beliefs could for example be stronger in unfamiliar disorders like schizophrenia than in more familiar disorders like alcoholism or depression. In this study we aim to close this gap by examining the relation between believing in a continuum of symptom experiences and attitudes towards persons with schizophrenia, depression and alcoholism. Following the concept of the stigma process proposed by Link and Phelan (2001 ), we expect continuum beliefs to be associated with more positive emotional reactions towards the affected persons and with less social rejection.

2. Methods

2.1. Survey

In two waves during March and April 2011 and November and December 2011, we conducted a representative population survey in Germany among adult persons of German nationality (>18 years) living in private households. The sample was drawn using a random sampling procedure with three stages: (1) electoral wards, (2) households, and (3) individuals within the target households. Target households within the sample points were determined according to the random route procedure; target persons were selected according to random digits. Informed consent was considered to have been given when individuals agreed to complete the interview. Fieldwork was done by USUMA (Berlin), a company specialised in marked and social research. Altogether, 3642 persons completed the interview, reflecting a response rate of 64.0%. Although containing slightly more women and less better-educated and single respondents, our sample can be considered representative of the German population ( Table 1 ).

Table 1 Socio-demographic characteristics of the population sample.

  Total population 2010 a Survey 2011 (n=3642)
Gender
Men 48.6 45.6
Women 51.4 54.4
 
Age    
 18–25 11.3 8.5
 26–45 31.9 30.7
 46–60 26.9 28.5
 >61 29.9 32.4
 
Education b    
 Unknown/pupil 1.0 0.7
 No schooling completed 4.0 3.4
 8/9 years of schooling 38.5 38.9
 10 years of schooling 29.3 39.5
 12/13 years of schooling 27.1 17.5
 
Marital status    
 Married 51.9 53.8
 Divorced 9.5 12.0
 Widowed 9.1 11.9
 Single 29.5 22.3

a Data from the Statistical Office Germany.

b Only persons ≥20 years, population data for younger persons not available.

2.2. Interview and case-vignettes

Personal, fully structured interviews were conducted face-to-face. The interview started with presenting randomly an unlabelled case-vignette of a person with either schizophrenia, depression or alcohol dependence. This resulted in independent sub-samples ofn=1235 respondents being presented a schizophrenia vignette,n=1220 being presented a depression vignette, andn=1187 being presented a vignette depicting an alcohol dependent person. The gender of the person described varied at random. Identical vignettes had been used in earlier surveys, which were constructed to be consistent with the diagnostic criteria of the respective disorders in DSM-III-R and had undergone validation by blinded experts in psychopathology ( Angermeyer and Matschinger, 1997 ).

2.3. Measures

2.3.1. Identification as mental illness

Following the presentation of the unlabelled case-vignette, we asked respondents whether they considered the person described as suffering from a mental illness in a medical sense. Answers were coded as 1=yes, 2=no and 3=don't know. For our analyses, we used a dummy variable with 1=identification as mental illness.

2.3.2. Belief in a continuum of symptom experience

We further asked respondents to indicate their agreement with the following statement: “Basically we are all sometimes like this person. It's just a question how pronounced this state is.” Answers had to be given on a five-point Likert-scale, “1” indicating strong agreement and “5” indicating strong disagreement with the statement. We reversed this score for our analysis and used it as a continuous variable, a higher score thus indicating stronger belief in a continuum of symptom experience.

2.3.3. Emotional reactions

We presented respondents with a scale consisting of 10 items describing possible emotional reactions, asking them to indicate how they would react to the person described in the vignette. Answers were given on five-point Likert-scales anchored with 1=“applies completely” and 5=“does not apply at all”.

The Kaiser-Meyer-Olkin measure of sampling adequacy for all items was 0.78, making the scale eligible for factor analysis. We entered all responses into an exploratory principal-component factor analysis, yielding three factors with an eigenvalue >1. We performed varimax rotation of the three factors, resulting in un-correlated factor scores. Table 2 shows items, rotated factor loadings, Eigenvalues and the explained variance of the three factors. Together, the three factors accounted for a cumulative variance of 63%. We termed the first factor “fear”, the second “anger”, and the third “pro-social reactions”. Scores were reversed for our analyses, higher scores indicating stronger emotional reactions.

Table 2 Rotated factor loadings, emotional reactions to a person with schizophrenia, depression or alcohol dependence (n=3594).

Item Factor 1 “Fear” Factor 2 “Anger” Factor 3 “Pro-social”
I feel uncomfortable 0.85 0.12 −0.04
The person provokes fear 0.82 0.14 0.04
I feel insecure 0.76 0.17 0.07
I am amused −0.03 0.76 0.04
I react angrily 0.26 0.74 −0.10
I feel annoyed 0.25 0.73 −0.08
The person provokes my incomprehension 0.30 0.61 −0.22
I feel sympathy −0.10 0.12 0.81
I feel the need to help 0.02 −0.22 0.76
I feel pity 0.26 −0.21 0.66
 
Eigenvalue 3.11 1.92 1.21
Cumulative explained variance 31% 50% 63%
2.3.4. Social distance

Respondents were then asked how willing they would be to accept the person described in the vignette in various social relationships, using the social distance scale developed by Link et al. (1987) . This scale encompasses the following social situations: rent a room, work together, have as neighbour, let take care of a little child, have marry into family, introduce to friends, recommend for a job. With the help of 5-point Likert scales respondents could indicate to what extent they were willing or unwilling to engage in the proposed relationships. For our analyses, we used a sum-score of all seven items, higher scores indicating stronger desire for social distance.

2.3.5. Contact

We elicited previous contact to persons with mental illness by asking respondents whether they had themselves received mental health care previously or whether they knew anybody who had been treated for mental illness. Answers were coded 0=no previous contact and 1=any previous contact.

2.4. Statistical analysis

We performed a series of linear regression analyses, using the sem command of STATA version 12.1 ( StataCorp, 2011 ). For each of the three vignettes, we regressed the factor scores “fear”, “anger”, and “pro-social reactions” as well as desire for social distance as dependent variables on continuum belief, identification as mental illness, previous contact, gender, age and educational achievement. We report unstandardizied (B) and standardized coefficients (Beta). Unstandardized coefficients are best suited for comparisons between models, since standardization might differ in each model. In contrast, standardized coefficients facilitate comparison of different associations within one model if variables are coded differently. To find out whether the effect of continuum beliefs on social distance or emotional reactions differed between vignette conditions, we performed Wald-tests on the equality of the three parameters.

3. Results

Table 3 shows the prevalence of the belief in a continuum of symptom experience for schizophrenia, depression and alcohol dependence. While more than 40% indicated agreement with a continuum of symptoms for depression, only one in four respondents agreed to this statement with regard to schizophrenia and alcohol dependence. The strongest disagreement with continuum beliefs surfaced with schizophrenia, where almost half of respondents rejected the statement.

Table 3 Belief in a continuum of symptoms regarding an unlabelled case vignette of schizophrenia, depression and alcohol dependence. Population survey in Germany 2011. “Basically, we are all sometimes like this person. It's just a question as to how pronounced this state is.”

  Schizophrenia (n=1233) Depression (n=1217) Alcohol dependence (n=1179)
(%) (%) (%)
Agree 26.0 42.1 27.0
Undecided 24.8 32.9 30.0
Disagree 49.2 25.1 43.0

Answers on either side of the midpoint of the five-point Likert scales are collapsed into “agree” and “disagree”, respectively. Due to rounding, percentages do not always add up to 100.

With regard to illness identification, the percentages of respondents considering the person described as suffering from a mental illness were 83% in schizophrenia, 65% in depression, and 52% in alcohol dependence. To explore the relation between defining the condition as mental illness and continuum beliefs, we regressed continuum beliefs on illness definition, controlling for previous contact. In all three vignette conditions, defining the condition as illness was significantly, but weakly associated with lower continuum beliefs (schizophrenia: Beta −0.10,p=0.001,R20.01; depression: Beta −0.06,p=0.029,R20.04; alcohol dependence: Beta −0.08,p=0.006,R20.01).

Table 4 shows results of our regression analyses relating social distance and emotional reactions to continuum beliefs. Effects of continuum beliefs differed between the three emotional reactions. Generally, belief in a continuum was related to less fear, but more anger. These associations were weak (Beta −0.07 to −0.12), and did not differ statistically between the three disorders (Wald-testp=0.24 [fear] and 0.48 [anger]). In all three disorders, continuum beliefs were significantly associated with more pro-social emotional reactions. These effects differed between disorders, being largest for schizophrenia (B 0.23, Beta 0.30), and smallest for depression (B 0.16, Beta 0.19; Wald-testp=0.06). Similarly, belief in a continuum of symptoms was associated with lower desire for social distance in all three conditions, the strongest associations being observed in schizophrenia (B −1.59, Beta −0.31), the weakest in depression (B −0.92, beta 0.16; Wald-testp=0.005). Overall, our models explained between 2% and 12% of the variance, this amount being largest for social distance, and in the models related to a person with schizophrenia.

Table 4 Reactions to a case-vignette depicting a person with schizophrenia, depression, or alcohol dependence and belief in a continuum of symptoms. Linear regression analyses, controlled for contact and socio-demographic variables, unstandardized (B) and standardized (beta) coefficients.

Case-vignette   Fear Anger Pro-social reactions Social distance
    B Beta B Beta B Beta B Beta
Schizophrenia Continuum belief −0.10 −0.12 lowastlowastlowast 0.09 0.10 lowastlowastlowast 0.23 0.30 lowastlowastlowast −1.59 −0.31 lowastlowastlowast
(n=1191–1200) Identification as mental illness 0.33 0.12 lowastlowastlowast −0.13 −0.04 0.13 0.05 0.62 0.04
  Contact −0.14 −0.07 lowast −0.18 −0.09 lowastlowast 0.15 0.08 lowastlowast −1.24 −0.10 lowastlowastlowast
  Gender (1=female) 0.14 0.07 −0.16 −0.07 lowastlowast 0.17 0.09 lowastlowastlowast −0.58 −0.05
  Age (years) 0.00 0.02 −0.00 −0.02 0.00 0.02 0.05 0.12 lowastlowastlowast
  Education 0.04 0.03 −0.06 −0.05 0.03 0.02 0.32 0.04
R2 (%)   04 03 11 12
 
Depression Continuum belief −0.06 −0.07 lowast 0.06 0.07 lowast 0.16 0.19 lowastlowastlowast −0.92 0.16 lowastlowastlowast
(n=1182–1187) Identification as mental illness 0.26 0.13 lowastlowastlowast −0.04 −0.02 0.22 0.11 lowastlowastlowast 0.35 0.03
  Contact −0.17 −0.09 lowastlowast −0.20 −0.10 lowastlowastlowast 0.09 0.05 −1.29 −0.10 lowastlowastlowast
  Gender (1=female) 0.04 0.02 0.00 0.00 0.23 0.12 lowastlowastlowast 0.19 0.01
  Age (years) 0.00 0.02 −0.00 −0.03 0.00 0.01 0.05 0.15 lowastlowastlowast
  Education 0.03 0.03 −0.04 −0.03 0.05 0.05 −0.28 −0.04
R2 (%)   03 02 07 07
 
Alcoholism Continuum belief −0.05 −0.07 lowast 0.04 0.05 0.19 0.22 lowastlowastlowast −1.11 −0.21 lowastlowastlowast
(n=1136–1144) Identification as mental illness 0.16 0.09 lowastlowast −0.16 −0.08 lowastlowast 0.34 0.17 lowastlowastlowast −2.26 0.18 lowastlowastlowast
  Contact −0.21 −0.11 lowastlowastlowast −0.21 −0.10 lowastlowastlowast −0.01 −0.01 −0.55 −0.04
  Gender (1=female) 0.28 0.15 lowastlowastlowast -0.03 -0.01 0.03 0.02 0.51 0.04
  Age (years) 0.00 0.05 −0.00 −0.02 0.00 0.02 0.04 0.10 lowastlowastlowast
  Education 0.01 0.03 −0.08 0.07 lowast −0.02 −0.02 0.25 0.03
R2 (%)   05 03 09 10

lowast p<0.05.

lowastlowast p<0.01.

lowastlowastlowast p<0.001.

Other variables were also of influence. Identification of the problem described as mental illness generally increased both fear and pro-social reactions and reduced anger, the latter effect being significant only in alcohol dependence. While associated with insignificant increases in social distance in schizophrenia and depression, illness recognition decreased social distance in alcohol dependence. Contact reduced anger and fear in all three conditions, increased pro-social reactions in schizophrenia and was associated with less desire for social distance in schizophrenia and depression.

4. Discussion

We found support for our hypothesis that belief in a continuum of symptoms is associated with less desire for social distance, and generally with more positive emotional reactions. Promulgating a mental health–mental illness continuum could thus contribute to de-stigmatizing mental disorders. Notably, effects of continuum beliefs were mostly stronger than effects of previous contact to someone with mental illness, a factor that has long been recognized to reduce social distance towards persons with mental illness ( Angermeyer and Matschinger, 1997 ) and is part of many anti-stigma initiatives ( Evans-Lacko et al., 2012 ).

Our results need however to be discussed in the light of the limitations of our study. Yielding associations between continuum beliefs and attitudes, our study does not allow conclusions on causality. Experimental studies manipulating continuum explanations of mental illness are necessary to further explore this relationship. We used unlabelled case-vignettes, thus eliciting reactions to a description of symptoms and not to an illness label. Mentioning a diagnostic label might have decreased notions of symptom continuity and increased negative reactions. However, we did control our analyses for identification of the problem as mental illness by the respondents, and found the influence of continuity beliefs unaffected by this potentially confounding variable. Still, reactions to a case-vignette may differ from actual behaviour towards a real person with mental illness, and it would be necessary to compare enacted stigma between different diagnoses to determine the role of continuity beliefs more exactly. The explanatory power of our models was generally low, suggesting that other predictors not included in our models are potentially important determinants of stigmatizing attitudes. Finally, belief in a continuum of symptoms was assessed only with a single item. Assessment with a whole set of variables is desirable for future studies.

From a clinical point of view, it might be contra-intuitive to promote concepts of mental illness that relate to a continuum between mental health and mental illness. Although there is no serious contention to the view expressed by the US Surgeon General that “‘mental health’ and ‘mental illness’ may be thought of as two points on a continuum” ( Satcher, 2000 ), this view seems to conflict with the medical approach of psychiatry aiming to distinguish persons with mental disorders that need and are eligible for treatment from those who are mentally healthy. The debate about whether certain mental disorders should be considered categorical or dimensional has accompanied the development of DSM-5, for example with regard to personality disorders ( Trull et al., 2007 ), substance use disorders ( Helzer et al., 2006 ), psychosis ( Allardyce et al., 2007 ) and affective disorders ( Andrews et al., 2007 ), and has resulted in advocating a multi-facetted approach and implementing more dimensional aspects into DSM-5 ( Amercian Psychiatric Association, 2012 ). Interestingly both beliefs, the disorder presented being a mental illness and resembling common experience, are only weakly correlated and thus not mutually exclusive in our population sample. Messages educating the public about a multifaceted view on mental illness including categorical distinctions and dimensional approaches should thus resonate well with the public.

Our research shows that communicating the continuity aspect of mental disorders to the public might help to increase social acceptance of persons with mental illness. It also shows, however, that continuum beliefs have not only beneficial effects. The small increase in anger associated with continuum beliefs could point towards the negative consequences of losing the benefits of the sick role ( Parsons, 1951 ). Perceiving mental health problems as being on a continuum with everyone's “normal” experiences could delegitimize the ill person's illness-related behaviour and could thus provoke more anger. However, we found only weak evidence for a beneficial sick-role in schizophrenia and depression, since defining the problem as illness reduced anger only significantly in alcohol dependence, where it also decreased social distance and increased pro-social reactions. Potential sick-role benefits thus seem to be dependent on diagnosis. Still, one has to bear in mind that sick-role benefits seem to occur mostly in close personal relationships and might thus have remained undetected by our vignette based population survey ( Perry, 2011 ).

Altogether, our results suggest that the positive implications of continuum beliefs outweigh potential negative effects. Continuum beliefs were associated with greater likeliness to help, to show pity and feel sympathy for the affected person, and they were associated with less desire for social distance. Our second assumption, that continuum beliefs are most closely associated with more positive attitudes towards disorders that are unfamiliar to respondents, was only partially confirmed by our results. In accordance with our hypothesis, the association of continuum beliefs and attitudes was strongest in schizophrenia, which was also the disorder with the smallest proportion of respondents believing in a continuum of symptoms (26%). In depression, in contrast, where 42% of respondents agreed in a continuum of symptoms, the relationship between continuum beliefs on social distance was weakest. However, contrary to our expectations, associations between continuity beliefs and social distance were also considerably stronger in alcohol dependence than in depression, although alcohol problems may also be considered a highly prevalent and thus presumably familiar disorder. Interestingly, alcoholism was rated as being different to normal experiences in a manner quite similar to schizophrenia. Alcohol dependence is among the most severely stigmatized mental disorders ( Schomerus et al., 2011 ). Our findings can thus be interpreted as an indicator of a bi-directional relationship between continuity beliefs and stigmatizing attitudes: Stigmatizing attitudes towards a person with alcohol dependence could also cause negation of a continuity of symptoms in a disorder that per se should be familiar to a large proportion of respondents ( Schomerus, 2011 ).

In conclusion, our findings suggest that indeed low belief in a continuum of symptoms and negative attitudes towards persons with mental illness are associated in a way that is consistent with conceptual models of the stigma of mental disorder ( Link and Phelan, 2001 ; Link et al., 2004 ). This relationship is illness specific, and appears to be closest in schizophrenia. Continuity beliefs are in accordance with epidemiological studies on the prevalence of symptoms of most mental disorders and could thus play a useful role in future anti-stigma messages. Combining them with established approaches based on contact seems feasible, since contact and messages promulgating symptom continuity could easily complement each other ( Clement et al., 2010 ). However, experimental studies are warranted to examine whether increasing the belief in a continuum of symptoms does in fact decrease stigmatizing attitudes.

Acknowledgement

This study was funded by the Fritz-Thyssen-Stiftung (Az. 10.11.2.175).

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Footnotes

a Department of Psychiatry, University Medicine Greifswald, Greifswald, Germany

b HELIOS Hanseklinikum Stralsund, Stralsund, Germany

c Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany

d Institute of Medical Sociology and Health Economics, University of Hamburg, Hamburg, Germany

e Department of Public Health, University of Cagliari, Cagliari, Italy

f Center for Public Mental Health, Gösing am Wagram, Austria

lowast Corresponding author at: Department of Psychiatry, University Medicine Greifswald, HELIOS Hanseklinikum Stralsund, Rostocker Chaussee 70, 18437 Stralsund, Germany. Tel.: +49 3831 452109; fax: +49 3831 452105.

Editor's Comment:
From a representative population survey conducted in Germany in 2011, the authors found that, contrary to their expectations, associations between continuity beliefs (belief in a continuum of symptoms from mental health to mental illness) and social distance were considerably stronger in alcohol dependence than in depression, although alcohol problems may be considered a highly prevalent and thus presumably familiar disorder. Interestingly, alcoholism was rated as being different to normal experiences in a manner quite similar to schizophrenia. Alcohol dependence is among the most severely stigmatized mental disorders.

 

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