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Internalized Stigma, Quality of Life and Self Esteem in Chronic Schizophrenic Patients.

Byline: Syeda Razia Bukhari, Aliya Imtiaz, Noreena Akbar, Umamah Ashraf Malik and Arifa Gilani

Key words: Internalized stigma, quality of life, self esteem and chronic schizophrenic patients.


In earlier periods, when psychological ailments were linked to "demons" or related to some curses, public stigma is being faced by people who were suffering from psychological illnesses. In today's world, these mental illnesses are perceived as inherited, fatal, a symbol of individual weakness, irrepressible and hazardous, regardless of the developments in the treatment procedures of such disorders, however, fewer than 3% of psychologically ill patients could be characterized as hazardous.1

Psychologically ill people are stigmatized in many ways by the public, which consists of labelling, stereotyping, separation and discrimination etc. Public stigma often results in self- stigma as "Internalization of guilt, blameworthiness, desperateness, blame and fear of discrimination that is related with psychological disorders".2 It is well documented that individuals suffering from severe psychological ailments (e.g., schizophrenia, bipolar disorder) are the ones that face public and feel internalized stigma.3,4

Schizophrenia is a ceaseless mental issue described by maladaptive thought designs and poor passionate reactions.5 Schizophrenia is portrayed by impairments clinched alongside social functioning, including trouble creating what's more administering interpersonal relationships, issues working alternately setting off with school, and challenges looking after one-self.

Schizophrenia is accompanied by a "second illness" and is not just limited to its symptoms.6 The responses from social situation, the labels that relate to the illness. Stigmatization is regarded as the dimension of suffering that is additional to the experience of illness, which leads to social isolation, where life chances are limited and individual's help seeking behavior is delayed.7

Different aspects associated to the perseverance of stigma against the psychologically ill, the likelihood of unusual and strange behavior that are unwanted and unpredictable with customs of the society; the risk of impulsive act as an outcome of being out of individual's mind; the danger of suicide and self-harm; the way that mass media depicts psychologically ill in an exaggerated way; resistance to psychiatric treatment that is sometimes regarded similar to "brainwashing"; the devastating effects of psychosis displayed through functional impairments; and stigmatization by the family whereby psychological disorders are viewed as "inherited in the family due to bad genes".

According to recent research, self-esteem become poor due to self-stigmatization. Depression, social conflict, poor quality of life, negativity and self-blame increase because of lack of social support and high internalized stigmatization.8-9

Number of recent researches reported the significant negative relationship between internalized stigma of mental illness and quality of life and self-esteem.10-13

Stigmatizing attitudes toward schizophrenic patients are common and remain a burden for the stigmatized individuals as well as a major clinical and public health issue. Stigma surrounding schizophrenia may result in delayed treatment, thereby increasing risks for health problems, abnormal behavior, and violence. The effects of internalized stigma on the schizophrenic patient's quality of life and self-esteem is negative such as they experienced psychological stress, depression and other psychiatric morbidity, fear, marital and relationship problems, restrictions from social participation. Persons with schizophrenia are often exposed to public prejudice, and they may consequently come to internalize negative attitudes about their own group, frequently leading to self- stigma.14 Therefore, the present study was aimed to investigate the internalized stigma as negative predictor of quality of life and self-esteem in chronic schizophrenic patients.

Patients and Methods

This study was conducted in 2017. Fifty chronic schizophrenic patients were enrolled in the study (27 females and 23 males) from various hospitals and clinics of Rawalpindi and Islamabad with an age range of 18-50 years. All the patients were selected from in patient's department of hospital, who were already diagnosed with schizophrenia and under treatment. Purposive convenient sampling technique was used to access the targeted sample. Three instruments were used in the research.

To measure internalized stigma, Internalized Stigma of Mental Illness Scale (ISMI) 15 urdu version was used. This scale has been translated in large number of languages and available online. There were initially 55 items in the scale, after screening 29 items were created. The internal consistency reliability of the 55-item version scale was excellent i.e. ([alpha] =0.92). ISMI is a four point Likert scale, 1=strongly disagree; 2=disagree; 3=agree; 4=strongly agree. Higher the scores on Internalized Stigma of Mental Illness scale indicated higher level of Internalized Stigma of Mental Illness and lower the score on ISMI indicated lower level of Internalized Stigma of Mental Illness.

Quality of Life Brief (WHOQOL)16 was used to assess Quality of life which was easy to administer and did not impose a burden on the respondent. The quality of Life Brief scale is a 26- item version of the WHOQOL-100 assessment. WHOQOL-BRIEF has good for excellent psychometric properties of reliability and performs well in preliminary tests of validity. Quality of life operationally defined as the combined scores on each of domain of this scale i.e. low scores represent low quality of life and high score represent high quality of life. This scale has been translated by Laghari, Alam, Ayub, Akhtar and Khan in Urdu in 2003 the scale has high test-retest reliability (r =0.84) and validity is 0.6716.

Rosenberg Self-Esteem Scale,17 the purpose of the 10 item RSE scale was to measure self- esteem. Responses of "disagree" or "strongly disagree" on items 1, 3, 4, 7, 10, indicate low self- confidence and "strongly agree" or "agree" on items 2, 5, 6, 8, 9 describe high self-esteem. Scoring of the scale is done by totaling the score of 4-point item after doing reverse coding of negative items. The alpha reliability of the scale ranges from.85 to.88. Reliability of Urdu Rosenberg Self Esteem Scale (URSES) was inferred by Cronbach's Alpha that is 0.773 and 4 weeks test re-test correlation coefficient was 0.808.17

Data was collected through survey questionnaires by the researcher. Permission from the respective institute was sought. Confidentiality of the data was ensured through obtaining informed consent from the participants before administering the questionnaires. Participants were free to leave the study at any stage if they find any inconvenience. They were informed that the data (their names and responses) will be kept confidential. After giving such information, all the three questionnaires were completed along with demographic sheet.

Statistical analysis was carried out using SPSS-18. To summarize the data, descriptive statistics were computed. Pearson correlation coefficient was conducted to assess the relationship between variables. Independent sample t-test was used to see the effects of the gender. Linear regression analyses were applied to assess the variables of study.


The mean age of the participants was 33.56 years. The mean age of males was 33.08 and females was 33.96 years. The mean value for Internalized Stigma of Mental Illness Scale 10 was 82.68 and for Quality of Life Brief scale11 was 59.38 and for Rosenberg Self-Esteem Scale12 was 14.7.

Table-1 depicts Linear Regression Analysis with ISMI as predictor of quality of life among chronic schizophrenic patients [R =.453, R2 =.205, F (1, 49) = 12.371, p <.001. [R =.326, R2 =.106, F (1, 49) = 5.705, p <.021].

Table 1: Linear regression analysis of ISMI and quality of life.

Quality of Life




Table-2 shows coefficients summary of regression analysis with ISMI as predictor of self- esteem among chronic schizophrenic patients. It also reveals the summary of Linear Regression Analysis with ISMI as predictor of self-esteem among chronic schizophrenic patients. [R =.326, R2 =.106, F (1, 49) = 5.705, p <.021].

Table 2: Linear regression analysis of ISMI and self- esteem.






This research was intended to explore internalized stigma as negative predictor of quality of life and self-esteem in chronic schizophrenic patients. Number of pervious research studies were in line with findings of current study.10-14 Patients having high level of internalized stigma will experience low level of self-esteem because they turn every public stigmatization and negative stereotyping toward themselves. Patients having low level of self-esteem cannot compete with the society and don't get any social support from the surroundings. Therefore, the self-esteem of patient's suffering from chronic schizophrenia should be improved by using different problem-solving strategies, by giving them care, focusing on their positives and setting challenges for them.

Patients suffering from chronic schizophrenia tend to be high on internalized stigma which in turn affect their quality of life very badly. These people may develop negative thinking, social conflicts and hopelessness which can harm their mental and psychological health. The best way to overcome internalized stigma is to develop hope and self-esteem among these patients. By introducing positive coping styles to resolve their conflicts and provision of social support, internalized stigma can be reduced.

Findings of the present study suggested that internalized stigma is a significant negative predictor of quality of life supporting previous literatures, such as; internalized stigma is negatively linked to quality of life and self-esteem.18,19

Schizophrenia contains an extended history of negligence, demonization and cover-up. The public attention is not given to the illness and study funding warranted by the numbers of people and families affected. To minimize the impact of illness upon community awareness, the affected families hide the illness from friends, workplace associates and relatives.

Individuals with schizophrenia are stigmatized, therefore it stops them from getting the kind of help and support that is required to manage the illness, which then leads to loneliness and social segregation. The negative costs of stigma include judgement in housing, employment and education, and more feelings of desperateness in people with schizophrenia and significantly influencing the quality of life and self-esteem of schizophrenic patients.

This study finding help us in planning stigma reduction strategies for schizophrenic patients. Two methods for reduction of self- stigmatization have developed. Firstly, interventions were used to change the individual beliefs and attitudes that are stigmatizing, and secondly those interventions were utilized that improve individual's skills to cope with self-stigmatization by improving the person's self-confidence, help-seeking behaviors and authorization.20

The sample size was smaller due to limited availability of sample and that limits the generalizability of the findings. Different intervention programs are required to overcome the issues of schizophrenic patients and their families as well. Qualitative method of research can be useful to explore the needs in this area. Further work is needed in evaluating self-stigma interventions; many of these studies have been exploratory or pilot investigations with limitations such as small sample size, lack of randomization, and no control group.15

Continuing with these types of studies will advance the body of research from describing the phenomena of stigma and self-stigma to refining treatment programs that will aid individuals with schizophrenia and other serious mental illnesses in their rehabilitation.

Internalized stigma is a significant negative predictor of quality of life and self-esteem in chronic schizophrenic patients. The study revealed about the level of internalized stigma and how it impacts on self-esteem and quality of life of chronic schizophrenic patients and how it can be helpful to provide key implications to overcome internalized stigma, enhance their self-esteem and quality of life, which is necessary for their well-being.

Conflict of interest: None declared.


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Publication:Pakistan Journal of Medical Research
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2019
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