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Guest Editorial
Considerations on the Stigma of Mental Illness
Julio Arboleda-Flórez
(PDF)

In Review
Stigma and the Daily News: Evaluation of a Newspaper Intervention
Heather Stuart
(PDF)

Interventions to Reduce the Stigma Associated With Severe Mental Illness: Experiences From the Open the Doors Program in Germany
Wolfgang Gaebel, Anja E Baumann
(PDF)

Determinants of the Public’s Preference for Social Distance From People With Schizophrenia
Matthias C Angermeyer, Michael Beck, Herbert Matschinger
(PDF)

Review Paper
Addiction: A Disease of Volition Caused by a Cognitive Impairment
William G Campbell
(PDF)

Defining Anxious Depression: Going Beyond Comorbidity
Peter H Silverstone, Erica von Studnitz
(PDF)

Original Research
Psychiatric Distress Among Road Rage Victims and Perpetrators
Reginald G Smart, Mark Asbridge, Robert E Mann, Edward M Adlaf
(PDF)

Risk of Weight Gain Associated with Antipsychotic Treatment: Results From the Canadian National Outcomes Measurement Study in Schizophrenia
Roger S McIntyre, Kostas Trakas, Daryl Lin, Robert Balshaw, Pieway Hwang, Kimberly Robinson, Andrew Eggleston
(PDF)

An Open-Label Study of Nefazodone Treatment of Major Depression in Patients With Congestive Heart Failure
François Lespérance, Nancy Frasure-Smith, Marc-André Laliberté, Michel White, Sylvain Lafontaine, Angelino Calderone, Mario Talajic, Jean-L Rouleau
(PDF)

Subtypes of Schizophrenia: A Cluster Analytic Approach
Edward Helmes, Jhan Landmark
(PDF)

Book Reviews
(PDF)

Counselling Problem Gamblers: A Self-Regulation Manual for Individual and Family Therapy.
Reviewed by
John Telner, PhD, CPsych

Letters to the Editor
(PDF)

Bongs, a Method of Using Cannabis Linked to Dependence

Obsessive–Compulsive Symptoms in Schizophrenia Induced by Risperidone and Responding to Fluoxetine

Lengthy Period of Incarceration as Personal Treatment Goal

Autoamputation in Psychosis: Diagnostic Issues

A Preliminary Report on Substance Use Patterns in an Adolescent Psychiatric Population

Facialis Palsy Attributable to Depot Antipsychotic Therapy

Recognizing Complicated Grief in Clinical Practice

In Review

Determinants of the Public’s Preference for Social Distance From People With Schizophrenia

Matthias C Angermeyer, MD¹, Michael Beck, DiplSoz², Herbert Matschinger, PhD³

In recent years, several programs have been initiated to reduce stigma and discrimination related to mental illness in general or to schizophrenia in particular (1–3). To reach this goal, numerous strategies have targeted the various stages of the stigma process (4). Quite often, unfortunately, strategies have had to be chosen primarily based on intuition rather than on empirical evidence (5). Only recently have conceptualizations of stigma’s various components been proposed that may prove helpful for planning antistigma activities (6–8). Only recently, as well, have first attempts been made to test the effectiveness of different antistigma strategies empirically, using social-psychological experiments (for example, 9–12).

This study is based on data from a representative survey. It examines the extent to which social distance is influenced by people’s beliefs about schizophrenia; that is, their ability to recognize symptoms of mental illness, their causal attributions, and their expectations concerning illness prognosis. It also examines the most pervasive stereotypes about schizophrenia sufferers; that is, that they are unpredictable and dangerous (13). The following questions are addressed: Which has a stronger impact on social distance, misperceptions about the illness or misperceptions about people suffering from it? Who, therefore, might be more promising candidates for antistigma interventions?

We also test the following propositions derived from stigma theory:

• As suggested by labelling theory, whether schizophrenic behaviour is perceived as mental illness should affect people’s preferences for social distance (14). Those who identify someone as suffering from the spectrum of mental illness are expected to express a stronger desire for social distance.

• According to attribution theory (15,16), if the causes of the disorder are attributed to factors outside individual control (for example, biological factors), the public’s reaction ought to be less negative. Conversely, if the cause of the disorder is attributed to supposed individual character flaws, the public will be less willing to interact with them.

• According to Jones and others, people with schizophrenia should be at a greater risk of stigma if their illness is perceived as having a poor prognosis (17).

Methods

Sample
In spring 2001, we conducted a representative survey in Germany, involving persons of German nationality aged 18 years or over. We drew the sample using a 3-stage, random- sampling procedure with electoral wards at the first stage, households at the second, and individuals within the target households at the third stage. 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. In total, we conducted 5025 interviews, which reflects a response rate of 65.1%. Regarding sex and age, the sample is comparable to the whole of the German population aged 18 years and over in 2000 (18).

Interview
The personal, fully structured interview began with the presentation of a vignette containing a diagnostically unlabelled psychiatric case history that in fact depicted a case of either schizophrenia or major depression. The symptoms described in the vignettes fulfilled the criteria of DSM-III-R for the respective disorders. The vignettes had been submitted to 5 psychiatrists or psychologists (all proven experts on psychopathology) for blind diagnostic allocation. All experts were able to provide the correct diagnoses for both case histories. Random subsamples were presented with only 1 vignette. In this paper, we use only interviews with the vignette depicting someone suffering from schizophrenia (n = 2481).

Measures

Social Distance
To assess respondents’ desire for social distance, we made use of a scale developed by Link (19), which is a modified version of the Bogardus Social Distance Scale (20). The scale includes 7 items representing the following social relationships: landlord, coworker, neighbour, member of the same social circle, personal job broker, in-law, child care provider. Using a 5-point Likert scale ranging from 1 = “in any case” to 5 = “in no case at all,” the respondents could indicate the extent to which they would, in the situation presented, accept the person described in the vignette. With the 7 items, we carried out a nonlinear principal component analysis (21) that provides so-called optimal scores both for the item categories and for each observation. The object scores of the first axis were used as indicators for social distance. High scores indicate a desire for greater social distance. The reliability of the scale, assessed by means of Cronbach’s alpha, is 0.90.

Problem Definition
Respondents were asked an open-ended question to discover how they would label the problem described in the vignette. The interviewers noted down responses to be coded later according to a coding system that had already proved useful in previous surveys (22). Four main categories were distinguished: 1 = correct psychiatric diagnosis, 2 = other psychiatric illness or psychiatric illness unspecified, 3 = personal problem (that is, an acute life crisis or chronic difficulty), 4 = other labels. We checked interrater reliability by having 2 people code 200 interviews independently. Cohen’s kappa reached 0.85.

Causal Attributions
Respondents’ attributions of the causes of the schizophrenia depicted in the vignette were assessed by responses to 10 items, with 2 items each referencing either psychosocial stress (such as a life event or stress at work), conditions of socialization (such as a broken home or lack of parental affection), biological causes (such as brain disease or heredity), intrapsychic causes (such as lack of will power or unconscious conflict), or deviant behaviour (such as alcohol abuse or an immoral life style). According to a 5-point Likert scale ranging from 1 = “definitely no cause” to 5 = “definitely a cause,” the responses should indicate how relevant respondents considered each potential cause to be.

Anticipated Prognosis
With regard to the prognosis for the problem described in the vignette, we suggested 5 different possibilities: complete cure, complete remission with the risk of relapse, partial remission, persistence of the problem, or progressive deterioration. The respondents were asked to choose a single category to indicate their assessment of the prognosis.

Personal Attributes
We asked the respondents to indicate, with the help of a 5-point Likert scale ranging from 1 = “definitely not true” to 5 = “definitely true,” whether they felt the individual depicted in the vignette to be unpredictable and dangerous, or not.

Results

As shown in Table 1, most respondents (71%) perceived the problem described in the vignette to be a mental illness. Among the sources of the problem, psychosocial stress and biological factors predominate. The main causes invoked were life events (72.5%), brain disease (69%), hereditary factors (59%), and chronic stress in the form of work difficulties (59%). Alcohol abuse was held responsible by 53% of the respondents. Having grown up in a broken home was less frequently considered to be at the root of the problem (40%), followed by lack of will power (37%) and lack of parental affection (15%). Thus, respondents tended to adopt causal attributions that are supported by psychiatric research rather than those that are not in accordance with it. Respondents felt rather gloomy about the further course: 69% expected the present condition to deteriorate. The individual depicted in the vignette was considered unpredictable by 54% of the respondents and dangerous by 30%.

In the next step, we investigated whether preferences to avoid social contact with schizophrenia sufferers are differentially influenced by what is known about the illness and by which personal attributes are attached to someone suffering from it. Table 2 shows the results of the regression of respondents’ desire for social distance on the predictor variables. Model 1 displays the results of the baseline model that expresses social distance as a function of the 4 sociodemographic characteristics: sex, age, education, and place of residence. Model 2 adds to the equation the set of variables referencing the respondents’ recognition of the described problem as mental illness, their causal attributions, and their expectations concerning the prognosis. Finally, model 3 assesses the effect of attributing unpredictability and dangerousness to the depicted individual by adding these 2 variables on the final step.

In the baseline model 1, the coefficients indicate that socio- demographic characteristics have a minimal impact, accounting for only 1.4% of the variance in expressed desire for social distance. Only age is found to significantly influence stated preferences for avoiding social contact with people suffering from schizophrenia: the older the respondents, the stronger the tendency to shun these people.

In model 2 we ask, net of sociodemographic characteristics, whether knowledge about schizophrenia—that is, recognition as mental illness, causal attributions, and anticipated prognosis—affects preferences for social distance. As predicted, respondents who identified the subject depicted in the vignette as suffering from mental illness were more likely to report a desire to avoid these people. Also as expected, respondents who blamed the individual for the disorder’s development (that is, for an immoral lifestyle or alcohol abuse) were more likely to express a desire for social distance. By contrast, those who perceived the disorder to be the result of the conditions under which someone grew up were less likely to say that they would shun the individual. Contrary to what might be predicted, respondents who attributed the disorder to a brain disease, as well as those who endorsed hereditary influences, tended to be less rather than more willing to make contact with the individual depicted in the vignette. Finally, respondents who reckoned with a bad prognosis showed a stronger preference for social distance. Taken together, these illness-related variables add 8.5 % to explained variance.

In model 3, we add the 2 personal attributes (unpredictability and dangerousness) to the model tested. As shown in Table 2, both strongly influence social distance, increasing considerably the public’s expression of the desire to avoid contact with people having schizophrenia. The independent impact of the 2 variables is a powerful component of our model of social distance, accounting for an additional 9.7% of explained variance. In addition, the perceptions of dangerousness and unpredictability have a mediating effect, attenuating by one-third the influence of perception of the problem as mental illness and by over one-half the influence of its attribution to a brain disease. As well, these 2 variables reduce to non- significance the effect of causal attributions to heredity and immoral life style.

With regard to desire for social distance, the importance of the perception that people with schizophrenia are unpredictable and dangerous becomes even more evident if both personal attributes and beliefs about the disorder are entered in reverse order into the regression equation. When added directly after sociodemographic characteristics, the 2 personal attributes account for not less than an additional 14.9%. When the perception of the problem as mental illness is added in the third model, causal attributions and perceived prognosis only increase explained variance by 3.3%.

Discussion

Our findings suggest that both labelling and beliefs about the causes and prognosis of schizophrenia, as well as the perceptions of those suffering from it as being unpredictable and dangerous, influence the public’s desire for social distance. However, our findings also suggest that it is the latter which is of greater importance. Perceived unpredictability and dangerousness explain a larger amount of variance and mediate part of the effect of illness beliefs on desire for social distance. The implications for antistigma interventions are evident. To reduce the discrimination experienced by people with schizophrenia, it seems particularly important to focus efforts on these misperceptions. What complicates the issue is the abundant evidence from recent epidemiological studies that the relative risk for violent crimes is in fact somewhat higher among people with schizophrenia, compared with the general population (23). However, increasing evidence also indicates that the attributable risk—that is, the proportion of violent crime in society committed by people with schizophrenia—is rather small (24,25). This sharply contrasts with the public’s perception of the great danger posed by people with schizophrenia. As pointed out by Walsh and others, the public should be informed about both types of risk (25). If data on only relative risk are reported, a skewed picture may emerge, and preexisting stereotypes may be reinforced. However, to convey these 2 risk concepts to the public may prove difficult, and thus, it may not be easy to change these stigmatizing misperceptions (13).

Our findings are in line with labelling theory. As expected, respondents who identified the depicted disorder as mental illness expressed a stronger desire for social distance than those who did not recognize it as such. Our findings also support the notion that the assumption of a poor prognosis increases the risk of stigmatization. Concerning causal attributions, our results are rather mixed. In accordance with attribution theory, the more respondents tended to blame the person for the disorder, the more they reported a desire for social distance. However, endorsing biological factors as cause was not associated with reduced social distance. Quite the opposite, the more respondents attributed the disorder to brain disease or heredity, the more they tended to distance themselves from the person depicted in the vignette. Finally, locating the cause in the way the person had been brought up was associated with a decreased desire for social distance. One faces the paradoxical situation that endorsing causes which are rather unsupported by empirical evidence is associated with less rejection, while endorsing causes considered to be well supported by research findings is associated with increased social distance.

Against this backdrop, the current emphasis of destigma- tization programs on educating the public about the biological nature of schizophrenia appears problematic. If the behaviour of persons with mental illness is seen as the result of chemical imbalances and genetic flaws, it may follow that they are considered to have little or no control over their behaviour and are therefore not responsible for it. This assumption may lead the layperson to conclude that the persons with mental illness are unpredictable and violent (26). Believing in biological aberrations may increase rather than decrease the separation from “them”—individuals considered to be very different from “us”—and, consequently, intensify the desire for distance (7). Teaching the public the biological model of schizophrenia may make people more knowledgeable about the state of psychiatric research and may improve their “mental health literacy” (27); however, this may not increase their understanding of persons suffering from the disorder or allow them to become more accepting.

Funding and Support

The project was supported by the German Research Association (grant AN 101/5-1).

References

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Author(s)

Manuscript received and accepted August 2003.

1. Head, Department of Psychiatry, University of Leipzig, Leipzig, Germany.

2. Research Associate, Department of Psychiatry, University of Leipzig, Leipzig, Germany.

3. Senior Researcher, Department of Psychiatry, University of Leipzig, Leipzig, Germany.

Address for correspondence: Dr MC Angermeyer, Department of Psychiatry, University of Leipzig, Johannisallee 20, D-04317 Leipzig, Germany

e-mail: krausem@medizin.uni-leipzig.de

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