Author's Accepted Manuscript
Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia Branka Aukst-Margetić, Nenad Jakšić, Vlatka Boričević Maršanić, Miro Jakovljević
www.elsevier.com/locate/psychres
PII: DOI: Reference:
S0165-1781(14)00378-3 http://dx.doi.org/10.1016/j.psychres.2014.05.009 PSY8277
To appear in:
Psychiatry Research
Received date: 17 October 2013 Revised date: 28 April 2014 Accepted date: 5 May 2014 Cite this article as: Branka Aukst-Margetić, Nenad Jakšić, Vlatka Boričević Maršanić, Miro Jakovljević, Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2014.05.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia
Branka Aukst-Margeti a,*, Nenad Jakši a, Vlatka Borievi Maršani b, Miro Jakovljevi a
a
Department of Psychiatry, University Hospital Center Zagreb, Zagreb, Croatia
b
Psychiatric Hospital for Children and Youth, Zagreb, Croatia
*
Correspondence:
Branka Aukst-Margeti, MD, PhD Department of Psychiatry, University Hospital Center Zagreb Kišpatieva 12, 10 000 Zagreb, Croatia E-mail: [email protected]
Abstract This study investigated the associations between internalized stigma, depressive symptoms, and temperament dimension Harm avoidance. One hundred and seventeen stable outpatients with schizophrenia completed a battery of self-report instruments. Internalized stigma was significantly positively related to depressive symptoms, while Harm avoidance moderated the internalized stigma – depressive symptoms relationship.
Keywords: Internalized stigma; Depression; Harm avoidance
1. Introduction Previous studies have found high levels of internalized stigma (or self-stigma) among patients with schizophrenia, and these subjective experiences have been linked with numerous negative outcomes, such as low self-worth, social isolation, increased symptom severity, and poorer treatment adherence (see Gerlinger et al., 2013). Further, internalized stigma is often associated with depressive symptoms (Park et al., 2013) and hopelessness (Yanos et al., 2008) among schizophrenia patients, even in prospective research (Lysaker et al., 2007; Corrigan et al., 2011). However, the literature is somewhat mixed as several studies have not confirmed these associations (see Gerlinger et al., 2013). Despite these relatively robust associations, little is known about potential factors that contribute to the development and intensity of internalized stigma, and processes that lie behind its relationship with depression and hopelessness. Indeed, a recent meta-analysis has called for more studies investigating moderator variables, such as personality traits, of the
complex association between stigma and various relevant outcomes (Livingston and Boyd, 2010). The relevance of personality traits with regard to various psychopathological outcomes in patients with schizophrenia has been receiving increased attention. The psychobiological model of personality developed by Cloninger et al. (1993) might be especially relevant as temperament dimensions are conceptually linked with different genetic and neurobiological underpinnings. The temperament dimension Harm avoidance (HA), defined as sensitivity to aversive stimuli that evoke negative emotions such as anticipatory worry and fear (Cloninger et al., 1993), is known to be elevated and associated with depressive symptoms in schizophrenia patients (Aukst-Margeti et al., 2009). It should be noted, however, that HA is increased and related to depression in various psychiatric populations, while the combination of high HA with low Reward Dependence may be a more specific characteristic of schizophrenia (Miettunen and Raevuori, 2012). Moreover, it was previously shown that HA serves as a unique predictor of internalized stigma in this population (Aukst-Margeti et al., 2010). Having in mind the need for identifying conditions and patients’ characteristics that can intensify the negative consequences of stigma (Livingston and Boyd, 2010), it might be prudent to examine whether HA potentiates depressive symptoms among patients experiencing internalized stigma (i.e., acts as a moderating factor). To our knowledge, no previous study has examined personality as a potential moderator of this relationship. Based on the abovementioned findings, we hypothesized that internalized stigma would be positively associated with depressive symptoms. We also expected temperament dimension HA to be a significant moderator of the stigma – depression relationship, such that experienced stigma would be associated with depressive symptoms to a larger extent in patients who also exhibited higher levels of HA.
2. Methods
2.1. Participants A sample of 117 Caucasian outpatients (68 male), with a diagnosis of schizophrenia established through the Mini International Neuropsychiatric Interview (Lecrubier et al., 1997), were recruited throughout the course of a year at two psychiatric institutions. The mean age of the patients was 34.1 years, S.D. 10.51 (range 19-64), while the mean duration of illness was 7.2 years, S.D. 6.90 (range 0.3-30). The patients were clinically stable for a minimum of three months and all were at least once hospitalized for mental illness. Exclusion criteria were mental retardation, organic brain disease, severe physical disorders, lifetime and current drug/alcohol abuse, and low comprehension skills. Eleven patients refused to participate, but they showed no significant differences in age and gender. Informed consent was obtained after the aim of the study was thoroughly explained. The study was approved by the ethics committees of the two institutions.
2.2. Measures The temperament dimension HA was assessed with the self-report scale of the Temperament and Character Inventory (TCI; Cloninger et al., 1994). It consists of 35 items requiring a true/false response. The scale comprises four subscales but we used the total HA score for the current study. Cronbach's = 0.79. The Internalized Stigma of Mental Illness (ISMI; Ritsher et al., 2003) was used to assess the participants’ subjective experience of stigma. This self-report questionnaire consists of 29
items rated on a 4-point Likert scale and contains five subscales (Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal, and Stigma Resistance). We used the total ISMI score for the current study. Cronbach's = 0.89. The Beck Depression Inventory (BDI; Beck et al., 1979) total score was used as a selfreport measure of acute depressive symptoms. It consists of 21 items assessed on a 3-point Likert scale. Cronbach's = 0.90.
2.3. Data analyses We performed all the data analyses by using the SPSS 17.0. Descriptive analysis included means and standard deviations. Pearson correlations were computed to examine the zero-order relationship among the variables. The possible moderating role of HA on the internalized stigma – depressive symptoms association was estimated by performing a hierarchical regression analysis in which depressive symptoms were the dependent variable. Age and gender were entered as covariates at step one to control for these theoretically relevant factors. Internalized stigma as the independent variable was entered in the second block, HA as the possible moderator was entered in the third block, and the interaction variable (independent variable multiplied by the moderator variable) was entered in the fourth block. As recommended by Kraemer and Blasey (2004), we standardized and centered all three variables in order to reduce multicollinearity and to facilitate interpretation of the coefficients. Further, separate regression analyses were conducted for participants who scored in the upper quartile and for those who scored in the lower quartile on the HA measure, while the statistical difference in the two coefficients was analyzed using the Fisher r-to-z transformation method (Cohen et al., 2003). We defined the level of statistical significance as P less than 0.05.
3. Results The total mean score of internalized stigma was 62.2 (S.D. 12.88), while the mean depression score was 10.7 (S.D. 9.73). Finally, the mean HA score was 19.1 (S.D. 7.04). Internalized stigma was highly positively correlated with depressive symptoms (r= 0.57, P< 0.001) and moderately with HA (r= 0.47, P< 0.001). There was also a large positive correlation between HA and depressive symptoms (r= 0.60, P< 0.001). The results of the hierarchical multiple regression analysis are presented in Table 1. After controlling for age and gender, internalized stigma was found to account for a significant 33% of the variance in depressive symptoms. Moreover, HA was found to account for a significant amount of additional variance in depressive symptoms (R2 = 13%). Finally, the interaction between HA and internalized stigma significantly predicted depressive symptoms over and above previous steps (R2 = 3%) (Table 1). To further analyze the interaction effect, we conducted separate regression analyses for participants who scored in the upper quartile (n=36) and for those who scored in the lower quartile (n=32) on the HA measure. These analyses confirmed the moderating effect of HA, as the association of internalized stigma with depressive symptoms was stonger among participants in the upper quartile ( = 0.65, P < 0.01) compared with those in the lower quartile ( = 0.37, P < 0.05). Finally, the Fisher r-to-z transformation method showed a marginally significant difference in these two coefficients (z = 1.52, P = 0.06) when a onetailed statistical approach was used.
4. Discussion As hypothesized, we observed a strong positive association between internalized stigma and depressive symptoms in schizophrenia outpatients. This is in accordance with some of the previous research (Lysaker et al., 2007; Park et al., 2013), although a recent meta-analysis (Gerlinger et al., 2013) indicated mixed results concerning this association. However, we believe some of these inconsistencies are due to certain measurement issues. For example, the lack of a significant correlation between internalized stigma and depression (although a positive trend was observed) in the study by Yanos et al. (2008) could be in part attributed to the single-item measure of depressive symptoms and the consequential variance reduction. Our results provide additional support that depression might be one of the psychopathological outcomes of internalized stigma in schizophrenia patients. More importantly, the results of this study supported our hypothesis that schizophrenia patients’ personality acts as a significant moderating factor in the internalized stigma – depression relationship. Internalized stigma was significantly associated with depressive symptoms at various levels of temperament dimension HA, but the strength of the association increased as HA increased, even after controlling for age and gender. Besides being a risk factor for internalized stigma (Aukst-Margeti et al., 2010), HA also seems to function as an ‘emotional amplifier’ that potentiates subjective experience of internalized stigma to augment the risk of depression. In other words, schizophrenia patients who are sensitive to aversive stimuli (i.e., high on HA) are more likely to endorse stigmatizing beliefs and anticipate social rejection. They are also prone to passive and avoidant coping strategies (Cloninger et al., 1993) that seem to increase the risk of depressive reactions following the development of internalized stigma. However, the relationship between internalized stigma and negative outcomes is complex and includes numerous potential moderating and mediating effects (e.g., social network, self-esteem, hope) (Corrigan et al., 2011; Mashiach-Eizenberg et al., 2013).
Thus, future studies should examine the role of personality traits at various stages of the progressive model of internalized stigma. Clinically, it seems that therapists working with schizophrenia patients should explore their personality structure when addressing the subjective experience of internalized stigma. In order to reduce the risk of depressive reactions, clinicians should aim their psychoeducational approach regarding internalized stigma at patients who tend to be harm avoidant. However, heritable and biologically based temperament dimensions such as HA could partly explain the difficulties in therapeutic attempts to reduce internalized stigma (Gerlinger et al., 2013). This assumption is in accordance with previous findings that HA and similar personality traits, such as Neuroticism, are negative prognostic factors in various therapies for depression, including psychotherapy (Kampman and Poutanen, 2011). It seems that individuals with higher scores on this trait experience intense levels of negative affect (e.g., pessimism, fear of uncertainty, shyness, asthenia) and may be too emotionally dysregulated to recruit the psychological resources needed to enable emotional and cognitive strategies required for the treatment of subjective experiences related to internalized stigma. However, there is some evidence suggesting a decrease in HA following pharmacological treatment of depressed patients (Kampman and Poutanen, 2011), while it was also reported that patients who scored higher on neuroticism responded better to antidepressant medication than to psychotherapy (Bagby et al., 2008). Thus, one of the indirect ways to alleviate the negative consequences of internalized stigma, might lie in the reduction of harm avoidant traits, particularly via psychopharmacological approach. A detailed and clinically useful description of psychopharmacological efforts in the context of the Psychobiological model of personality, can be found elsewhere (Svrakic and Cloninger, 2013). This study has several limitations that need to be mentioned. The main limitation was its cross-sectional design, so future longitudinal research is needed to confirm the moderating
role of personality in the prospective causal link between internalized stigma and depression. Second, only one personality dimension was proposed in this model, although internalized stigma is probably influenced by the interplay between various personality traits. Third, we used only the total ISMI score, so future studies should examine possible differentiating influence of personality on various aspects of stigma. In addition, generalization of the study results is somewhat limited by the sample composition. Our participants were ethnically uniform and they varied in terms of their age and length of illness, all of which are known to be associated with clinical and treatment outcome variables in schizophrenia. Thus, our findings need to be replicated in more homogenous studies with regard to age and length of illness, as well as in studies with ethnically diverse samples. Further, the limited size of the two subsamples (i.e., participants in the upper and lower quartile of HA) presumably led to only a marginally significant difference between the two correlation coefficients, although the correlation between internalized stigma and depression was qualitatively higher for participants who scored in the upper quartile on the HA measure. Finally, the MINI is limited concerning its evaluation of schizophrenia, while there was also no direct measure of schizophrenia symptoms in the current study. Because HA is known to be associated with negative symptoms, future research should investigate whether the observed moderating role of HA maintains significance after accounting for the potential contributions of negative symptoms. In summary, the main finding of this study was the moderating role of Harm avoidance in the internalized stigma - depressive symptoms relationship, such that HA amplifies subjective experience of internalized stigma to augment the risk of depression in patients with schizophrenia. Internalized stigma is known to be associated with various negative outcomes in this population, so the role of HA should be taken into consideration
during treatment and psychoeducation of these patients. Further clarification of these complex relationships requires longitudinal studies.
References
Aukst Margeti, B., Jakovljevi, M., Brataljenovi, T., Šumi, M., 2009. Personality and schizophrenia: psychobiological model and its relationship with comorbidity. Psychiatria Danubina 21, 356-360. Aukst Margeti, B., Jakovljevi, M., Ivanec, D., Margeti, B., Toši, G., 2010. Relations of internalized stigma with temperament and character inpatients with schizophrenia. Comprehensive Psychiatry 51, 603–606. Bagby, R.M., Quilty, L.C., Segal, Z.V., McBride, C.C., Kennedy, S.H., Costa, P.T., 2008. Personality and differential treatment response in major depression: a randomized controlled trial comparing cognitive-behavioural therapy and pharmacotherapy. Canadian Journal of Psychiatry 52, 361–370. Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitive therapy of depression. Guilford Press, New York, NY. Cloninger, C.R., Svrakic, D.M., Przybeck, T.R., 1993. A psychobiological model of temperament and character. Archives of General Psychiatry 50, 975-90. Cloninger, C.R., Pryzbeck, T.R., Svrakic, D.M., Wetzel, R., 1994. The Temperament and Character Inventory (TCI): a guide to its development and use. Washington University School of Medicine, Department of Psychiatry, St. Louis, MO.
Cohen, J., Cohen, P., West, S.G., Aiken, L.S., 2003. Applied multiple regression/correlation analysis for the behavioral sciences. Lawrence Erlbaum, Mahwah, NJ. Corrigan, P.W., Rafacz, J., Rusch, N., 2011. Examining a progressive model of self- stigma and its impact on people with serious mental illness. Psychiatry Research 189, 339–343. Gerlinger, G., Hauser, M., De Hert, M., Lacluyse, K., Wampers, M., Correll, C.U., 2013. Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry 12, 155-164. Kampman, O., Poutanen, O., 2011. Can onset and recovery in depression be predicted by temperament? A systematic review and meta-analysis. Journal of Affective Disorders 135, 20-27. Kraemer, H.C., Blasey, C.M., 2004. Centring in regression analyses: a strategy to prevent errors in statistical interference. International Journal of Methods in Psychiatric Research 13, 141-151. Lecrubier, Y., Sheehan, D.V., Weiller, E., Amorim, P., Bonora, I., Harnett Sheehan, K., Janavs, J., Dunbar, G.C., 1997. The Mini International Neuropsychiatric Interview MINI. A short diagnostic structured interview: reliability and validity according to the CIDI. European Psychiatry 12, 224-31. Livingston, J.D., Boyd, J.E., 2010. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta- analysis. Social Science & Medicine 71, 2150–2161. Lysaker, P.H., Davis, L.W., Warman, D.M., Strasburger, A., Beattie, N., 2007. Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months. Psychiatry Research 149, 89-95.
Mashiach-Eizenberg, M., Hasson-Ohayon, I., Yanos, P.T., Lysaker, P.H., Roe, D., 2013. Internalized stigma and quality of life among persons with severe mental illness: the mediating roles of self-esteem and hope. Psychiatry Research 208, 15-20. Miettunen, J., Raevuori, A., 2012. A meta-analysis of temperament in axis I psychiatric disorders. Comprehensive Psychiatry 53, 152-166. Park, S.G., Bennett, M.E., Couture, S.M., Blanchard, J.J., 2013. Internalized stigma in schizophrenia: relations with dysfunctional attitudes, symptoms, and quality of life. Psychiatry Research 205, 43-7. Ritsher, J.B., Otilingam, P.G., Grajales, M., 2003. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research 121, 31–49. Svrakic, D.M., Cloninger, C.R., 2013. Psychobiological Model of Personality: Guidelines for Pharmacotherapy of Personality Disorder. Current Psychopharmacology 2, 190-203. Yanos, P.T., Roe, D., Markus, K., Lysaker, P.H., 2008. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services 59, 1437–1442.
Table 1 Hierarchical regression analysis showing amount of variance accounted for in depressive symptoms by internalized stigma, Harm avoidance, and the Harm avoidance x internalized stigma interaction.
B
R2
R2
F
0.03
0.03
2.66
Depressive symptoms Step 1 Age
0.02
0.21*
Gender
0.05
0.02
Step 2
Internalized stigma
0.56
0.56**
0.33
0.30
51.88**
0.41
0.41**
0.46
0.13
27.24**
0.18
0.17*
0.49
0.03
6.28*
Step 3 Harm avoidance Step 4 Harm avoidance x Internalized stigma
Note: N = 117; (B) = (non)standardized regression coefficient; R2 = additional variance explained in the step of regression analysis. * P < 0.05, ** P < 0.01.
Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia Branka Aukst-Margetić, Nenad Jakšić, Vlatka Boričević Maršanić, Miro Jakovljević
www.elsevier.com/locate/psychres
PII: DOI: Reference:
S0165-1781(14)00378-3 http://dx.doi.org/10.1016/j.psychres.2014.05.009 PSY8277
To appear in:
Psychiatry Research
Received date: 17 October 2013 Revised date: 28 April 2014 Accepted date: 5 May 2014 Cite this article as: Branka Aukst-Margetić, Nenad Jakšić, Vlatka Boričević Maršanić, Miro Jakovljević, Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2014.05.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Harm avoidance moderates the relationship between internalized stigma and depressive symptoms in patients with schizophrenia
Branka Aukst-Margeti a,*, Nenad Jakši a, Vlatka Borievi Maršani b, Miro Jakovljevi a
a
Department of Psychiatry, University Hospital Center Zagreb, Zagreb, Croatia
b
Psychiatric Hospital for Children and Youth, Zagreb, Croatia
*
Correspondence:
Branka Aukst-Margeti, MD, PhD Department of Psychiatry, University Hospital Center Zagreb Kišpatieva 12, 10 000 Zagreb, Croatia E-mail: [email protected]
Abstract This study investigated the associations between internalized stigma, depressive symptoms, and temperament dimension Harm avoidance. One hundred and seventeen stable outpatients with schizophrenia completed a battery of self-report instruments. Internalized stigma was significantly positively related to depressive symptoms, while Harm avoidance moderated the internalized stigma – depressive symptoms relationship.
Keywords: Internalized stigma; Depression; Harm avoidance
1. Introduction Previous studies have found high levels of internalized stigma (or self-stigma) among patients with schizophrenia, and these subjective experiences have been linked with numerous negative outcomes, such as low self-worth, social isolation, increased symptom severity, and poorer treatment adherence (see Gerlinger et al., 2013). Further, internalized stigma is often associated with depressive symptoms (Park et al., 2013) and hopelessness (Yanos et al., 2008) among schizophrenia patients, even in prospective research (Lysaker et al., 2007; Corrigan et al., 2011). However, the literature is somewhat mixed as several studies have not confirmed these associations (see Gerlinger et al., 2013). Despite these relatively robust associations, little is known about potential factors that contribute to the development and intensity of internalized stigma, and processes that lie behind its relationship with depression and hopelessness. Indeed, a recent meta-analysis has called for more studies investigating moderator variables, such as personality traits, of the
complex association between stigma and various relevant outcomes (Livingston and Boyd, 2010). The relevance of personality traits with regard to various psychopathological outcomes in patients with schizophrenia has been receiving increased attention. The psychobiological model of personality developed by Cloninger et al. (1993) might be especially relevant as temperament dimensions are conceptually linked with different genetic and neurobiological underpinnings. The temperament dimension Harm avoidance (HA), defined as sensitivity to aversive stimuli that evoke negative emotions such as anticipatory worry and fear (Cloninger et al., 1993), is known to be elevated and associated with depressive symptoms in schizophrenia patients (Aukst-Margeti et al., 2009). It should be noted, however, that HA is increased and related to depression in various psychiatric populations, while the combination of high HA with low Reward Dependence may be a more specific characteristic of schizophrenia (Miettunen and Raevuori, 2012). Moreover, it was previously shown that HA serves as a unique predictor of internalized stigma in this population (Aukst-Margeti et al., 2010). Having in mind the need for identifying conditions and patients’ characteristics that can intensify the negative consequences of stigma (Livingston and Boyd, 2010), it might be prudent to examine whether HA potentiates depressive symptoms among patients experiencing internalized stigma (i.e., acts as a moderating factor). To our knowledge, no previous study has examined personality as a potential moderator of this relationship. Based on the abovementioned findings, we hypothesized that internalized stigma would be positively associated with depressive symptoms. We also expected temperament dimension HA to be a significant moderator of the stigma – depression relationship, such that experienced stigma would be associated with depressive symptoms to a larger extent in patients who also exhibited higher levels of HA.
2. Methods
2.1. Participants A sample of 117 Caucasian outpatients (68 male), with a diagnosis of schizophrenia established through the Mini International Neuropsychiatric Interview (Lecrubier et al., 1997), were recruited throughout the course of a year at two psychiatric institutions. The mean age of the patients was 34.1 years, S.D. 10.51 (range 19-64), while the mean duration of illness was 7.2 years, S.D. 6.90 (range 0.3-30). The patients were clinically stable for a minimum of three months and all were at least once hospitalized for mental illness. Exclusion criteria were mental retardation, organic brain disease, severe physical disorders, lifetime and current drug/alcohol abuse, and low comprehension skills. Eleven patients refused to participate, but they showed no significant differences in age and gender. Informed consent was obtained after the aim of the study was thoroughly explained. The study was approved by the ethics committees of the two institutions.
2.2. Measures The temperament dimension HA was assessed with the self-report scale of the Temperament and Character Inventory (TCI; Cloninger et al., 1994). It consists of 35 items requiring a true/false response. The scale comprises four subscales but we used the total HA score for the current study. Cronbach's = 0.79. The Internalized Stigma of Mental Illness (ISMI; Ritsher et al., 2003) was used to assess the participants’ subjective experience of stigma. This self-report questionnaire consists of 29
items rated on a 4-point Likert scale and contains five subscales (Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal, and Stigma Resistance). We used the total ISMI score for the current study. Cronbach's = 0.89. The Beck Depression Inventory (BDI; Beck et al., 1979) total score was used as a selfreport measure of acute depressive symptoms. It consists of 21 items assessed on a 3-point Likert scale. Cronbach's = 0.90.
2.3. Data analyses We performed all the data analyses by using the SPSS 17.0. Descriptive analysis included means and standard deviations. Pearson correlations were computed to examine the zero-order relationship among the variables. The possible moderating role of HA on the internalized stigma – depressive symptoms association was estimated by performing a hierarchical regression analysis in which depressive symptoms were the dependent variable. Age and gender were entered as covariates at step one to control for these theoretically relevant factors. Internalized stigma as the independent variable was entered in the second block, HA as the possible moderator was entered in the third block, and the interaction variable (independent variable multiplied by the moderator variable) was entered in the fourth block. As recommended by Kraemer and Blasey (2004), we standardized and centered all three variables in order to reduce multicollinearity and to facilitate interpretation of the coefficients. Further, separate regression analyses were conducted for participants who scored in the upper quartile and for those who scored in the lower quartile on the HA measure, while the statistical difference in the two coefficients was analyzed using the Fisher r-to-z transformation method (Cohen et al., 2003). We defined the level of statistical significance as P less than 0.05.
3. Results The total mean score of internalized stigma was 62.2 (S.D. 12.88), while the mean depression score was 10.7 (S.D. 9.73). Finally, the mean HA score was 19.1 (S.D. 7.04). Internalized stigma was highly positively correlated with depressive symptoms (r= 0.57, P< 0.001) and moderately with HA (r= 0.47, P< 0.001). There was also a large positive correlation between HA and depressive symptoms (r= 0.60, P< 0.001). The results of the hierarchical multiple regression analysis are presented in Table 1. After controlling for age and gender, internalized stigma was found to account for a significant 33% of the variance in depressive symptoms. Moreover, HA was found to account for a significant amount of additional variance in depressive symptoms (R2 = 13%). Finally, the interaction between HA and internalized stigma significantly predicted depressive symptoms over and above previous steps (R2 = 3%) (Table 1). To further analyze the interaction effect, we conducted separate regression analyses for participants who scored in the upper quartile (n=36) and for those who scored in the lower quartile (n=32) on the HA measure. These analyses confirmed the moderating effect of HA, as the association of internalized stigma with depressive symptoms was stonger among participants in the upper quartile ( = 0.65, P < 0.01) compared with those in the lower quartile ( = 0.37, P < 0.05). Finally, the Fisher r-to-z transformation method showed a marginally significant difference in these two coefficients (z = 1.52, P = 0.06) when a onetailed statistical approach was used.
4. Discussion As hypothesized, we observed a strong positive association between internalized stigma and depressive symptoms in schizophrenia outpatients. This is in accordance with some of the previous research (Lysaker et al., 2007; Park et al., 2013), although a recent meta-analysis (Gerlinger et al., 2013) indicated mixed results concerning this association. However, we believe some of these inconsistencies are due to certain measurement issues. For example, the lack of a significant correlation between internalized stigma and depression (although a positive trend was observed) in the study by Yanos et al. (2008) could be in part attributed to the single-item measure of depressive symptoms and the consequential variance reduction. Our results provide additional support that depression might be one of the psychopathological outcomes of internalized stigma in schizophrenia patients. More importantly, the results of this study supported our hypothesis that schizophrenia patients’ personality acts as a significant moderating factor in the internalized stigma – depression relationship. Internalized stigma was significantly associated with depressive symptoms at various levels of temperament dimension HA, but the strength of the association increased as HA increased, even after controlling for age and gender. Besides being a risk factor for internalized stigma (Aukst-Margeti et al., 2010), HA also seems to function as an ‘emotional amplifier’ that potentiates subjective experience of internalized stigma to augment the risk of depression. In other words, schizophrenia patients who are sensitive to aversive stimuli (i.e., high on HA) are more likely to endorse stigmatizing beliefs and anticipate social rejection. They are also prone to passive and avoidant coping strategies (Cloninger et al., 1993) that seem to increase the risk of depressive reactions following the development of internalized stigma. However, the relationship between internalized stigma and negative outcomes is complex and includes numerous potential moderating and mediating effects (e.g., social network, self-esteem, hope) (Corrigan et al., 2011; Mashiach-Eizenberg et al., 2013).
Thus, future studies should examine the role of personality traits at various stages of the progressive model of internalized stigma. Clinically, it seems that therapists working with schizophrenia patients should explore their personality structure when addressing the subjective experience of internalized stigma. In order to reduce the risk of depressive reactions, clinicians should aim their psychoeducational approach regarding internalized stigma at patients who tend to be harm avoidant. However, heritable and biologically based temperament dimensions such as HA could partly explain the difficulties in therapeutic attempts to reduce internalized stigma (Gerlinger et al., 2013). This assumption is in accordance with previous findings that HA and similar personality traits, such as Neuroticism, are negative prognostic factors in various therapies for depression, including psychotherapy (Kampman and Poutanen, 2011). It seems that individuals with higher scores on this trait experience intense levels of negative affect (e.g., pessimism, fear of uncertainty, shyness, asthenia) and may be too emotionally dysregulated to recruit the psychological resources needed to enable emotional and cognitive strategies required for the treatment of subjective experiences related to internalized stigma. However, there is some evidence suggesting a decrease in HA following pharmacological treatment of depressed patients (Kampman and Poutanen, 2011), while it was also reported that patients who scored higher on neuroticism responded better to antidepressant medication than to psychotherapy (Bagby et al., 2008). Thus, one of the indirect ways to alleviate the negative consequences of internalized stigma, might lie in the reduction of harm avoidant traits, particularly via psychopharmacological approach. A detailed and clinically useful description of psychopharmacological efforts in the context of the Psychobiological model of personality, can be found elsewhere (Svrakic and Cloninger, 2013). This study has several limitations that need to be mentioned. The main limitation was its cross-sectional design, so future longitudinal research is needed to confirm the moderating
role of personality in the prospective causal link between internalized stigma and depression. Second, only one personality dimension was proposed in this model, although internalized stigma is probably influenced by the interplay between various personality traits. Third, we used only the total ISMI score, so future studies should examine possible differentiating influence of personality on various aspects of stigma. In addition, generalization of the study results is somewhat limited by the sample composition. Our participants were ethnically uniform and they varied in terms of their age and length of illness, all of which are known to be associated with clinical and treatment outcome variables in schizophrenia. Thus, our findings need to be replicated in more homogenous studies with regard to age and length of illness, as well as in studies with ethnically diverse samples. Further, the limited size of the two subsamples (i.e., participants in the upper and lower quartile of HA) presumably led to only a marginally significant difference between the two correlation coefficients, although the correlation between internalized stigma and depression was qualitatively higher for participants who scored in the upper quartile on the HA measure. Finally, the MINI is limited concerning its evaluation of schizophrenia, while there was also no direct measure of schizophrenia symptoms in the current study. Because HA is known to be associated with negative symptoms, future research should investigate whether the observed moderating role of HA maintains significance after accounting for the potential contributions of negative symptoms. In summary, the main finding of this study was the moderating role of Harm avoidance in the internalized stigma - depressive symptoms relationship, such that HA amplifies subjective experience of internalized stigma to augment the risk of depression in patients with schizophrenia. Internalized stigma is known to be associated with various negative outcomes in this population, so the role of HA should be taken into consideration
during treatment and psychoeducation of these patients. Further clarification of these complex relationships requires longitudinal studies.
References
Aukst Margeti, B., Jakovljevi, M., Brataljenovi, T., Šumi, M., 2009. Personality and schizophrenia: psychobiological model and its relationship with comorbidity. Psychiatria Danubina 21, 356-360. Aukst Margeti, B., Jakovljevi, M., Ivanec, D., Margeti, B., Toši, G., 2010. Relations of internalized stigma with temperament and character inpatients with schizophrenia. Comprehensive Psychiatry 51, 603–606. Bagby, R.M., Quilty, L.C., Segal, Z.V., McBride, C.C., Kennedy, S.H., Costa, P.T., 2008. Personality and differential treatment response in major depression: a randomized controlled trial comparing cognitive-behavioural therapy and pharmacotherapy. Canadian Journal of Psychiatry 52, 361–370. Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitive therapy of depression. Guilford Press, New York, NY. Cloninger, C.R., Svrakic, D.M., Przybeck, T.R., 1993. A psychobiological model of temperament and character. Archives of General Psychiatry 50, 975-90. Cloninger, C.R., Pryzbeck, T.R., Svrakic, D.M., Wetzel, R., 1994. The Temperament and Character Inventory (TCI): a guide to its development and use. Washington University School of Medicine, Department of Psychiatry, St. Louis, MO.
Cohen, J., Cohen, P., West, S.G., Aiken, L.S., 2003. Applied multiple regression/correlation analysis for the behavioral sciences. Lawrence Erlbaum, Mahwah, NJ. Corrigan, P.W., Rafacz, J., Rusch, N., 2011. Examining a progressive model of self- stigma and its impact on people with serious mental illness. Psychiatry Research 189, 339–343. Gerlinger, G., Hauser, M., De Hert, M., Lacluyse, K., Wampers, M., Correll, C.U., 2013. Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry 12, 155-164. Kampman, O., Poutanen, O., 2011. Can onset and recovery in depression be predicted by temperament? A systematic review and meta-analysis. Journal of Affective Disorders 135, 20-27. Kraemer, H.C., Blasey, C.M., 2004. Centring in regression analyses: a strategy to prevent errors in statistical interference. International Journal of Methods in Psychiatric Research 13, 141-151. Lecrubier, Y., Sheehan, D.V., Weiller, E., Amorim, P., Bonora, I., Harnett Sheehan, K., Janavs, J., Dunbar, G.C., 1997. The Mini International Neuropsychiatric Interview MINI. A short diagnostic structured interview: reliability and validity according to the CIDI. European Psychiatry 12, 224-31. Livingston, J.D., Boyd, J.E., 2010. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta- analysis. Social Science & Medicine 71, 2150–2161. Lysaker, P.H., Davis, L.W., Warman, D.M., Strasburger, A., Beattie, N., 2007. Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months. Psychiatry Research 149, 89-95.
Mashiach-Eizenberg, M., Hasson-Ohayon, I., Yanos, P.T., Lysaker, P.H., Roe, D., 2013. Internalized stigma and quality of life among persons with severe mental illness: the mediating roles of self-esteem and hope. Psychiatry Research 208, 15-20. Miettunen, J., Raevuori, A., 2012. A meta-analysis of temperament in axis I psychiatric disorders. Comprehensive Psychiatry 53, 152-166. Park, S.G., Bennett, M.E., Couture, S.M., Blanchard, J.J., 2013. Internalized stigma in schizophrenia: relations with dysfunctional attitudes, symptoms, and quality of life. Psychiatry Research 205, 43-7. Ritsher, J.B., Otilingam, P.G., Grajales, M., 2003. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research 121, 31–49. Svrakic, D.M., Cloninger, C.R., 2013. Psychobiological Model of Personality: Guidelines for Pharmacotherapy of Personality Disorder. Current Psychopharmacology 2, 190-203. Yanos, P.T., Roe, D., Markus, K., Lysaker, P.H., 2008. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services 59, 1437–1442.
Table 1 Hierarchical regression analysis showing amount of variance accounted for in depressive symptoms by internalized stigma, Harm avoidance, and the Harm avoidance x internalized stigma interaction.
B
R2
R2
F
0.03
0.03
2.66
Depressive symptoms Step 1 Age
0.02
0.21*
Gender
0.05
0.02
Step 2
Internalized stigma
0.56
0.56**
0.33
0.30
51.88**
0.41
0.41**
0.46
0.13
27.24**
0.18
0.17*
0.49
0.03
6.28*
Step 3 Harm avoidance Step 4 Harm avoidance x Internalized stigma
Note: N = 117; (B) = (non)standardized regression coefficient; R2 = additional variance explained in the step of regression analysis. * P < 0.05, ** P < 0.01.
