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Aspects of perceived stigma: The Stigma Inventory for Mental Illness, itsdevelopment, latent structure and psychometric properties

Maria Veroniki Karidi, Despoina Vasilopoulou, Eugenia Savvidou, SiliaVitoratou, Andreas D. Rabavilas, Constantinos N. Stefanis

PII: S0010-440X(14)00089-3DOI: doi: 10.1016/j.comppsych.2014.04.002Reference: YCOMP 51282

To appear in: Comprehensive Psychiatry

Received date: 19 June 2013Revised date: 7 April 2014Accepted date: 7 April 2014

Please cite this article as: Karidi Maria Veroniki, Vasilopoulou Despoina, SavvidouEugenia, Vitoratou Silia, Rabavilas Andreas D., Stefanis Constantinos N., Aspectsof perceived stigma: The Stigma Inventory for Mental Illness, its development, la-tent structure and psychometric properties, Comprehensive Psychiatry (2014), doi:10.1016/j.comppsych.2014.04.002

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Title:

Aspects of perceived stigma: the Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties. Authors:

Maria Veroniki Karidi1,*, Despoina Vasilopoulou1, Eugenia Savvidou1,

Silia Vitoratou2, Andreas D. Rabavilas1, Constantinos N Stefanis1

1Psychosocial Vocational Rehabilitation Unit (PVRU). University Mental Health Research

Institute (UMHRI), Athens, Greece.

2Biostatistics Department, Institute of Psychiatry, King’s College London, UK.

* Author of Correspondence:

Dr. Maria Veroniki Karidi Psychosocial Vocational Rehabilitation Unit, University Mental Health Research Institute, 2 Soranou tou Efessiou 15601 Athens, Attica, Greece Phone: 00302106170915 Fax: 00302106170917 E-mail: vkaridi@epipsi.gr

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Aspects of perceived stigma: the Stigma Inventory for Mental

Illness, its development, latent structure and psychometric

properties.

Authors: Maria Veroniki Karidi, Despoina Vasilopoulou, Eugenia Savvidou, Silia Vitoratou, Andreas

D. Rabavilas, Constantinos N Stefanis

Abstract

Objective: The aim of this study was to develop a new brief and easy to administer self-stigma scale

for mental illness as well as to assess the correlations between self-stigma and psychopathology of

chronic schizophrenic patients.

Methods: The Stigma Inventory for Mental Illness (SIMI) was administered to 100 outpatients

diagnosed with schizophrenia. Psychopathology and overall functioning were assessed with the

Positive and Negative Symptom Scale (PANSS) and Global Assessment Scale (GAS), respectively.

Results: The final scale consists of 12 items. Factor analysis concluded to two dimensions:

perceptions of social stigma and self-efficacy. Both factors were found to be reliable (high internal

consistency and stability coefficients). Significant correlations were present with psychopathology,

functioning and selected items from the Community Attitudes toward the Mentally Ill (CAMI)

inventory.

Conclusion: The SIMI scale is a reliable and valid psychometric tool that can be used to assess

patient’s self-stigma and self-efficacy. The findings suggest also that psychopathology has an

immediate effect on endorsing self-stigmatizing attitudes.

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Introduction

Scientific literature indicates that everyday life and functioning of mentally ill patients are severely

affected by stigma. Given the universality of this tendency [1], the World Health Organization now

considers stigma as a global health problem [2].

Stigma is a general term composed of intertwined concepts, such as social, experienced and

internalized stigma. Munoz et al. [3] define social stigma as the set of negative attitudes and beliefs

that the public adopts towards mentally ill patients. Social stigma differs from experienced stigma in

terms of the recipient of the stigmatizing attitudes; specifically, experienced stigma is - in a sense -

the consequence of social stigma, as it refers to the experienced discrimination due to the mental

illness. Internalized (or self) stigma refers to “the stigma endorsed by the people suffering from a

mental illness about them just for having their mental illness”. Other researchers argue that self-

stigma is “a process of identity transformation wherein a person loses their previously held or

desired identities to adopt a stigmatized view of themselves” [4].

The nature of schizophrenia per se (both for acute or chronic states) seems to facilitate the

endorsement of self-stigmatizing attitudes. The type and severity of the symptoms, the content of

schizophrenic thoughts and ideas, the awareness that one may not control oneself and the chronic

duration of the disorder are some of the illness’ characteristics that facilitate the emergence of a

negative and stigmatized self-image. Schizophrenia can be conceived as erosion not only in the

control of oneself but also in interpersonal relationships which is reflected in mistrust and

dependence on institutions ultimately leading to the loss of social status [5]. This seems to aggravate

patients’ internalizing stigma tendencies, which further interferes with their rehabilitation outcome,

as suggested by evidence from clinical practice.

It has been proposed that endorsing self-stigmatizing attitudes impedes the rehabilitation and

integration process in multiple ways as patients tend to blame themselves for the illness’ onset, are

inhibited from seeking help or job for fear of stigmatization [6] and withdraw from social

interactions, altogether affecting their quality of life. Consequently, treating self-stigma should be a

core component of every individualized therapeutic rehabilitation plan.

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In this context emerged the need for the development of a clinical instrument that would assess self-

stigmatizing attitudes in mentally ill patients.

Methods

Participants

One hundred chronic patients with schizophrenia, who attended the Psychosocial Vocational

Rehabilitation Unit (PVRU) of the University Mental Health Research Institute (UMHRI) were

recruited. Inclusion criteria were: diagnosis of schizophrenia (according to the Diagnostic and

Statistical Manual of Mental Disorders Revised [7]), stable symptomatology and compliance with the

medication regime. Exclusion criteria were: substance abuse, developmental disabilities and

neurological diseases. All patients were clinically examined and psychiatric records were formed,

including clinical interviews of the patients and their close relatives. All individuals were unemployed

upon entrance to the study.

The experimental design and procedure were reviewed and approved by the ethical committee of

the University Mental Health Research Institute and participants’ written informed consent was

granted.

Item development

The new scale was based on the Self-stigma Questionnaire (SSQ - [8]), developed by the PVRU of the

UMHRI. The SSQ delivers detailed information to the clinicians with respect to the patients’ point of

view towards their illness. However, clinical practice indicated the need for a short, robust

psychometric scale for the evaluation of stigma, able to provide clinicians and researchers with a

total score indicative of self-stigmatizing attitudes.

By taking into consideration the experience granted by clinical practice and by the patients’

responses to SSQ throughout the years, a pool of 20 items was initially proposed by the members of

a multidisciplinary research team (psychiatrists, psychologists, social workers and psychometricians).

All items reflected stigma (no negatively/inversed scored items were included), measured on a 5-

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point Likert scale varying from 1 (“no-never”) to 5 (“always”). The scale was designed to cover two

areas: relations with oneself and relations with others, which include two distinct roles, the social

and the professional role.

The assessment of the psychometric properties of the items and the scale in total, led to the

development of SIMI, a 12- item self-administered inventory, as described in detail at the following

sections.

Measures

The scale was administered during the first week of the patients’ participation in the program of the

PVRU, in order to exclude potential effects of the rehabilitation program to the responses. At the

same time, the patients’ pathology and functioning were evaluated by the program’s psychiatrists

utilizing PANSS [9] and GAS [10]. Finally, the CAMI [11,12] inventory was administered

synchronously, which also assesses aspects of stigma and additionally is standardised in Greek

language. Given that the CAMI evaluates mostly social stigma, only items referring to self-stigma

were considered.

Statistical Analysis

The factorial structure of the questionnaire was accessed via confirmatory factor analysis (using the

robust weighted least squares estimator [13,14]). This methodology takes under consideration the

ordinal nature of the items and is bias free as opposed to treating the Likert items as continuous

indicators. For the model evaluation, two absolute fit indices are reported here, namely the Root

Mean Square Error of Approximation (RMSEA) [15] and the relative chi-square [χ2/df; 16].

Furthermore, the fit of each model compared to the null (or independence) model was assessed by

using two relative fit indices: the Tucker- Lewis index (TLI) and the Comparative Fit Index (CFI) [17].

With respect to the reliability of the scale, the internal consistency was assessed via Cronbach’s

alpha coefficient (item level). Additionally, the test-retest reliability (stability) of the responses was

evaluated in a time interval of one month, using Pearson’s correlation coefficient (for the total and

factor scores).

The content (concurrent) validity of the scale was evaluated on the basis of the correlations of the

scale with the other measures. All analysis was undertaken using Mplus [18].

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Results

Demographic and clinical characteristics

The patients’ age (range: 22-68, mean=39.7, sd=9.4 years) and education level (first: 5%, second:

51%, third: 44%) did not differ significantly between genders. On the contrary, the mean age of the

illness onset was significantly lower for females (19.4 versus 22.4, Mann-Whitney U=710.5, p=0.013).

No significant differences were found between genders with regard to the psychopathology and

level of functioning as measured by PANSS (mean: 83.8, sd-=22.4) and GAS (mean: 52.6, sd-=14.7)

respectively. The majority of the individuals (82%) have been hospitalized at least once (in total, up

to one month: 13, up to one year: 56 and more than a year: 13 individuals).

Item selection

Two criteria were implemented for item selection, that is, items that a) reduced the total scale’s

reliability and/or b) provided loadings less than 0.2 (non-salient) in either the one-factor or the two-

factor solutions (described below) were omitted from the scale. The exclusion procedure was

conducted in a step-wise manner by re-evaluating at each point the consistency of the resulting set

of items. The final scale consists of the 12 items presented in Table 1.

TABLE 1 SHOULD BE PLACED HERE

Factor structure

The one (global) factor model was initially implemented, emerging adequate fit according to both

relative and absolute measures of fit (see Table 2). Specifically, the relative chi-square value was

lower than the threshold value of 2 and the RMSEA was 0.07 which indicates adequate fit according

to Browne and Cudeck [15]. The relative fit indices (TLI and CFI) were higher than the threshold of

0.9, confirming close fit.

The next step of the analysis was to evaluate the fit of multidimensional, theory-oriented models

suggested by the members of our research team. CFA results indicated that the best fitted model is

the two factor solution presented in Table 2. The fit indices were further improved (compared to the

global factor solution), while the context of the items further justified the factorial structure, in

terms of face validity.

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Based on the content of the items that load to each factor, the two dimensions identified are

hereafter referred to as the “perceptions of social stigma” and the “self-efficacy” factors (see also

Table 1).

TABLE 2 SHOULD BE PLACED HERE

Reliability assessment

The alpha coefficient was 0.90 for the total score and 0.85 and 0.75 for the first and second factors

respectively. These values are considered satisfactory, especially since the second factor is consisted

of four items while the alpha coefficient is dependent upon the number of items.

Test-retest reliability was evaluated by re-assessing a random sub-sample of 40 patients within one

month. The correlation of the total scores between assessments was 0.8 (p<0.001) while no

significant difference emerged between the total scores (mean difference=0.32, t=0.37, df = 39, p-

value = 0.715). Similarly, strong positive correlations were found on factor score level (perceptions of

social stigma: 0.8, p<0.001 and self-efficacy 0.7, p<0.001).

Correlations with demographic characteristics and clinical measures

The SIMI total score did not correlate with gender, age or the marital and economic status of the

patients. However, the years of education were found to be positively correlated with the total SIMI

score (r=0.25, p=0.011). Interestingly, it was the perceptions of social stigma factor that was

significantly correlated with the years of education (r=0.25, p=0.011) rather than the self-efficacy

subscale (r=0.19, p=0.054).

The SIMI total score did not correlate with GAS. However at factor level, GAS was found to be

negatively correlated with the perceptions of social stigma (r=-0.2, p=0.048). With respect to

psychopathology, SIMI correlated positively with the total PANSS score (r=0.21, p=0.035). In

particular, the association was mostly attributed to the positive (r=0.21, p=0.039) and general

symptoms (r=0.20, p=0.043). The correlation coefficients of the SIMI total and factor scores with

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each of the PANSS symptoms were presented in Table 3. In Table 4 are presented the correlations of

selected CAMI items with the SIMI scores. The results provide further evidence in favor of the

validity of SIMI.

TABLES 3 and 4 SHOULD BE PLACED HERE

Discussion

Based on previous evidence provided from the detailed SSQ measurements, our aim was to create a

brief scale that can be employed to correlate self-stigmatizing attitudes with the rehabilitation

outcome, that is, a quantitative description of the level of internalized negative self-image of the

patient. The results of this study indicate that SIMI is a short yet reliable and valid psychometric tool

for the measurement of self-stigmatizing attitudes of patients with schizophrenia.

The psychometric assessment of the responses indicated that the items reflect two dimensions of

self-stigma: “perceptions of social stigma” and “self-efficacy”. This finding agrees with previously

reported results, which conceptualize self-stigma as a complex construct comprising of discrete

processes, such as stereotype awareness and agreement and self-concurrence, which in turn have

an impact on self-esteem and self-efficacy [19]. In this context, a mentally ill patient perceives social

stigma against mental illness, in other words s/he is aware of the societal stereotype and endorses

it. Ultimately, this fact leads to diminished self-esteem and self-efficacy, eroding thus the patient’s

self-concept [20]. The distorted self-concept triggers feelings of shame [21] and depression [22],

emotions reflected in avoidance, secrecy and withdrawal in terms of behavioral responses [23, 24,

25].

The dimension of the “perceptions of social stigma” refers to the beliefs and attitudes about mental

illness that the patient had before the illness’s onset and his/hers own actual personal discriminative

experiences due to the illness [26]. By endorsing the social stigma and stereotypes about mental

illness, the patient behaves likewise. In contrast, “self-efficacy” refers to the ability to fulfill tasks and

achieve goals or expectations about that ability. Self-efficacy and self-esteem are the components of

self-image that are most affected by self-stigma. When a patient endorses the public stereotype

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about mental illness, composed of a helpless, weak or dangerous patient image, and adopts these

attributes, feelings of shame, devaluation, incompetence and depression surface, undermining self-

efficacy and self-esteem [23, 27, 28].

Correlation of demographical data and the full score of SIMI indicated that only educational level

seems to have a positive correlation with SIMI score; evidence that agrees with previous studies [29,

30]. In fact, educational level correlates positively with the “perceptions of social stigma” factor,

which can be attributed to the higher premorbid functioning, as well as the already formed social

belief about mental illness [23, 25, 31].

Results showed that the total score in the GAS correlates negatively with the “self-efficacy” factor. A

lower level of overall functioning has an immediate effect on the level of insight about the disease,

which in turn augments the self-stigmatizing attitudes [32]. As Mak and Wu have discussed, patients

with low or no insight do not recognise nor take in any possible stigmatizing attitudes towards them

[33].

As far as the possible relation between psychopathology and self-stigma is concerned, scientific

literature is not conclusive [34]. Our results show a positive relation between total PANSS and total

SIMI scores, contributing to findings from previous studies [33, 35, 36]. It seems that patients with

severe negative or positive symptomatology are the ones who experience stigma more intensely

[37].

It is also of notice that the total PANSS score is with the “perceptions of social stigma” factor. Prior

studies have shown that severe symptomatology may be related to higher levels of self-stigma as

clinical image of the disorder is more conspicuous and rejection of public stigma against mental

illness harder to be achieved [35 but see 38]. For instance, symptoms, such as anxiety,

suspiciousness and agitation have an immediate effect on the image the patients form about

themselves, given that those symptoms are easily detected and are discernible by patients and their

social environment. The negative self-evaluation provokes feelings of guilt about their condition, as

the individuals consider themselves responsible for the disease.

Patients that are emotionally withdrawn, who feel depressed [28, 39 but 35] and who actively avoid

social interactions are more likely to experience higher self-stigma, as they tend to adopt negative

stereotypes regarding the way they are treated by others as well as the way the see themselves [40,

41, 42].

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Statistical analysis of the data show that the PANSS score for positive symptoms correlates positively

with the total SIMI score, meaning that the presence of positive symptoms may be related with

higher self-stigma attitudes. This is not a novel finding as Lysaker et al. [32] have commented that

positive symptoms intensify the internalization of negative attitudes. Indeed, positive symptoms are

often considered by patients as a breach or threat to a stable and united concept of self. Stigma

literature proposes that endorsing stigmatizing attributes is facilitated when there has been a

disruption in self-concept [43].

With respect to the SIMI significant correlations with CAMI, societal beliefs concerning the

functioning and the efficacy of mentally ill patients seem to be reflected in the beliefs the mentally ill

patients have about their own efficacy. In addition, both society and mentally ill patients tend to

attribute the emergence of mental illness more often in negative personal characteristics, such as

lack of self-discipline or will power, rather than in conceptualizing mental illness as an interaction of

genetic and environmental factors. Ultimately, these negative beliefs – depicted in both scales – lead

to the adoption of the image of the mentally ill as a burden to society or to the adoption of a

negative image of the self.

Self-stigma is an important variable in the clinical outcome of schizophrenia and thus, should always

be included in the therapeutic plan. Indeed, self-stigma hinders seeking professional help [39, 40, 44,

45], complying with the treatment, seeking work or actively engaging in social interactions [41, 42,

46, 47].Therefore, incorporating the assessment and treatment of self-stigma in everyday clinical

practice will contribute to designing therapeutic programs for mental illness that will address real -

life issues, such as help-seeking, outcome and quality of life.

Limitations and conclusion

The statistical analysis of the SIMI questionnaire suggests that it is a valid and reliable, self-

administered scale for assessing self-stigma. The two factors emerged from factor analysis

(“perceptions of social stigma” and “self-efficacy”) indicate that the SIMI scale assesses self-stigma in

line with other studies that highlight these dimensions (among others) as basic components of self-

stigma [28, 38, 48]. The design of the SIMI however, fosters being used in clinical practice and

research, as it is brief, easy to understand/administer and can be a useful tool in providing

information on possible self-stigmatizing attitudes. The scale is developed specifically for mental

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illness, with emphasis in schizophrenia, reflecting therefore the most essential aspects of self-stigma

in psychosis.

The limitations of this study include the small sample size, the participation in social rehabilitation

programs [24] and the non-incorporation of cultural components of self-stigma.

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Table 1 Estimated loadings - two factor model.

Stigma Inventory for Mental Illness (SIMI)

Estimated

Loadings

Standard

Error*

F1

. P

erce

pti

on

s o

f S

oci

al

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a

02. Do you feel that you should keep your illness secret from your

social environment?

fixed (=1) -

03. Are you concerned that some of your friends may have been

estranged because of your illness?

1.27 0.12

04. Do you believe that one runs the risk of being fired if he/she

discloses that he/she suffers from a chronic illness?

1.07 0.12

05. Are you faced with difficulties in social contacts because you are

ashamed to talk about your problem?

0.98 0.14

06. Do you believe that it is likely that one’s social entourage will take

a distance if a chronic health problem becomes known?

1.33 0.13

07. Do you believe that if others knew about your illness, they would

change their attitudes towards you and avoid you?

1.10 0.12

08. Do you believe that your hospitalization affected your social

acceptance? 1.35 0.13

10. Do you feel that others will avoid you if they find out that you are

on medication because of your illness?

1.33 0.13

F2

. S

elf-

effi

cacy

01. Do you feel discouraged because of your illness? fixed (=1) -

09. Do you believe that your hospitalization affected your self-

acceptance?

1.00 0.12

11. Have you noticed that you avoid job seeking because of your

illness?

1.09 0.11

12. Do you believe that people suffering from chronic illnesses have

no chance of finding a job?

0.93 0.10

*all loadings were significant (p<0.001)

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Table 2 Measures of goodness of fit of the one and two factor models.

MODEL

Absolute fit measures Relative fit measures

χ2 (p-value) χ

2/df RMSEA TLI CFI

One-factor model 78.7 (0.016) 1.46 0.07 0.976 0.980

Two factors model 67.6 (0.085) 1.11 0.05 0.985 0.988

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Table 3 Spearman correlation coefficients of SIMI with GAS and PANSS (n=100).

Perceptions of Social

Stigma

Self-efficacy

Total SIMI

rho p-value rho p-

valu

e

rho p-

value GAS -0.20 0.048* -

0.06

0.337 -

0.1

8

0.075

PANSS 0.21 0.035 0.16 0.103 0.2

2

0.025

Positive symptoms 0.17 0.095 0.19 0.056 0.2

1

0.039

Negative symptoms 0.19 0.061 0.07 0.504 0.1

6

0.103

General symptoms 0.20 0.043 0.19 0.058 0.2

3

0.023

Selected PANSS items:

N02. Emotional withdrawal

withdrawalΣυναισθηματική

απόσυρση

0.23 0.023 0.18 0.075 0.2

3

0.021

P04. Excitement

0.15 0.126 0.21 0.037 0.1

8

0.078

P06.

Suspiciousness/persecution

0.28 0.005 0.31 0.002 0.3

4

0.001

G02. Anxiety 0.23 0.022 0.34 0.000 0.3

0

0.002

G03. Feelings of guilt 0.18 0.078 0.33 0.001 0.2

6

0.009

G06. Depression

0.22 0.028 -

0.03

0.762 0.1

5

0.127

G16. Active social avoidance 0.19 0.050 0.13 0.192 0.2

0

0.043

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Table 4 Spearman correlation coefficients of SIMI with selected items from CAMI (n=100).

Perception

s of

social

stigma

Self-

efficacy

Total SIMI

rh

o

p-

valu

e

rh

o

p-

valu

e

rh

o

p-

valu

e

B1. There are sufficient existing services for the mentally ill -

0.2

9

0.004 -

0.1

7

0.098 -

0.2

6

0.010

A2. There is something about the mentally ill that makes it easy to

tell them from normal people

0.2

4

0.017 0.1

8

0.068 0.2

4

0.019

S2. Most women who were once patients in a mental hospital can be

trusted as babysitters

-

0.1

5

0.135 -

0.2

2

0.032 -

0.1

9

0.056

A7. One of the main causes of mental illness is a lack of self-

discipline and will power

-

0.1

6

0.110 0.2

1

0.033 -

0.1

9

0.058

B2. The mentally ill are a burden on society -

0.1

3

0.188 0.2

2

0.027 -

0.1

8

0.068