ReviewStigma and bipolar disorder: A review of the literature
Introduction
“Psychiatric stigma” refers to systemic and internalized stereotypical negative attitudes against people labeled as mentally ill (Corrigan et al., 2011). It is a social injustice that goes hand in hand with discriminatory behaviors, causing direct harm to the individuals affected. Negative, stigmatizing attitudes common in today's society include beliefs that mental illness is a sign of personal deficit, weakness, deviance, low intelligence, unreliability or incompetence and that people with mental illness are violent and unpredictable (Harrison and Gill, 2010, Putman, 2008). This type of prejudice is found throughout society—in the general public, within the families and social circles of people with mental illness, among healthcare professionals, and even among affected individuals themselves (Sartorius et al., 2010).
The theoretical framework of stigma describes three intersecting levels: structural, social, and self-stigma. Structural stigma refers to the policies and practices of institutions, in positions of power, that systematically restrict the rights and opportunities for people living with mental illnesses (Corrigan et al., 2004, Herek, 2007, Livingston and Boyd, 2010). Social stigma refers to the process whereby large social groups endorsing stereotypes about people with stigmatized condition and act against them (Corrigan et al., 2005). Lastly, self-stigma refers to the internalization of societal attitudes and discriminatory practices (Crocker and Quinn, 2000, Major and O'Brien, 2005). Self-stigma is defined as a subjective state “characterized by negative feelings (about self), maladaptive behaviour, identity transformation, or stereotype endorsement resulting from an individual's experiences, perceptions, or anticipation of negative social reactions on the basis of their mental illness” (Livingston and Boyd, 2010). Self-stigma has serious impacts on the lives of individuals with mental illnesses and their families. It can be associated with withdrawal, social exclusion, and a reduced quality of life (Harrison and Gill, 2010). In some cases, internalized or self-stigma prevents treatment seeking (Eisenberg et al., 2009) or poses a barrier to optimal treatment provision (Verhaeghe and Bracke, 2011).
Bipolar disorder (BD) is no exception when it comes to stigma. BD is a severe mental illness characterized by episodes of major depression and mania (BD-I) or hypomania (BD-II) (American Psychiatric Association, 2001). People with BD tend to experience multiple affective relapses (Schaffer et al., 2006), substantial residual or inter-episode symptoms (Benazzi, 2004, Paykel et al., 2006), and high suicidality (Judd and Akiskal, 2003). With these symptoms come a myriad of impacts on psychosocial functioning, self-esteem, and quality of life (Blairy et al., 2004, IsHak et al., 2012). BD also imposes a considerable burden on families and caregivers (Van Der Voort et al., 2007).
Stigma is assessed in a variety of ways. A large body of research examines stigma using qualitative techniques. This approach has many advantages in examining stigma, as it allows researchers to explore the subtle, personal meaning that stigma has for different individuals. Quantitative self-report tools have also been developed. Among the commonly used tools is the Mental Illness Stigma Scale (MISS; Day et al., 2007), a general scale that can be administered to any adult population and that breaks the construct of stigma down into factors such as contact anxiety, hygiene, treatability, and the feasibility of recovery. Additional tools have been developed to assess stigma among specific populations. Examples include the Mental Illness Clinicians’ Attitude Scale (MICA; Kassam et al., 2010) and the Opening Minds Scale for Health Care Providers (OMS-HC; Kassam et al., 2012). Self-stigma is assessed with similar questionnaires that can be adapted to the disorder in question. A popular example is the Internalized Stigma of Mental Illness scale (ISMI; Ritsher et al., 2003), which looks at self-stigma from various angles, such as the sense of alienation, perceived discrimination, and social withdrawal. In an attempt to move away from attitudes-based assessment, Link et al. (1999) proposed a brief scale to measure the desire for social distance from individuals with mental illness, viewed as a proxy for stigmatizing behavior. Other methods of measurement include the use of vignettes to accompany assessments and implicit measures that seek to bypass social desirability. Methods of assessing stigma are more thoroughly reviewed elsewhere (Link et al., 2004, Stier and Hinshaw, 2007).
Through a program of community-based participatory research, the Collaborative RESearch team to study psychosocial factors in BD (CREST.BD) has identified stigma as a major concern for people with BD and their families (Michalak et al., 2011, Suto et al., 2012). CREST.BD is a multidisciplinary, cross-sectoral network dedicated to fundamental research and knowledge exchange on BD (Michalak et al., 2012). Based on its early findings, CREST.BD has established stigma reduction as a priority area for its work. However, a unified, effective campaign to fight BD-related stigma requires a clear understanding of the relationship between stigma and bipolarity. To this end, we conducted a review of the literature addressing the psychiatric stigma associated with BD.
Section snippets
Method
To identify literature addressing stigma and BD, the first author searched the PsychInfo, Medline, and Embase databases using the following search terms: “Stigma,” “Stigmatization,” “Bipolar disorder,” “Mania,” “Hypomania,” “Cyclothymia,” and “Stereotyping.” A database was created of all search results, from the earliest indexed articles to the search date of April 2012, and abstracts were reviewed for applicability. Reference lists of relevant articles were also examined for additional
Results
The search identified a variety of studies examining stigma as it pertains to BD. The majority of articles examined stigma as experienced by individuals with BD and/or their family members, although some articles studied the question from other, complementary viewpoints. Current conceptual understandings of stigma suggest the potential utility of viewing stigma through the lens of self-, public and structural stigma constructs. However, since many of the articles identified in this review
Discussion
This article systematically reviews the literature examining stigma toward bipolar disorder (BD). A considerable literature has addressed the issue, with a diversity of perspectives and approaches. In general, the literature shows that stigma is a major concern for individuals with BD and their family members. The sense of stigma is high in BD and appears to have considerable negative repercussions on social support, functioning and quality of life.
The stigma felt among individuals with BD
Role of funding source
Portions of this project were funded by the Canadian Institutes of Health Research. The funding body had no other role in the project.
Conflict of interest
None.
Acknowledgements
We would like to thank Stephen Hinshaw for his valuable feedback on this review paper.
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