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. Author manuscript; available in PMC: 2015 Jun 17.
Published in final edited form as: Psychiatr Rehabil J. 2015 Mar 23;38(2):125–131. doi: 10.1037/prj0000119

The relationship between stigma sentiments and self-identity of individuals with schizophrenia

Jennifer M Aakre a,✉, Elizabeth A Klingaman a, Nancy M Docherty b
PMCID: PMC4469555  NIHMSID: NIHMS666009  PMID: 25799298

Abstract

Objective

Stigma sentiments are the attitudes held towards a culturally-devalued label or group. The present study measures schizophrenia stigma sentiments and self-identity to assess self-stigma experienced by people with schizophrenia.

Methods

Ninety individuals with schizophrenia and 23 controls with no history of psychosis rated the evaluation, potency, and activity of “A person with schizophrenia or schizoaffective disorder,” (stigma sentiments) and of “Myself as I really am” (self-identity). T-tests, correlations, and regression analysis were employed to 1) test relationships among stigma sentiments and self-identity in the groups separately, 2) test a model for predicting self-identity in the schizophrenia group, using stigma sentiments, current symptoms, and current functioning, and 3) compare the participant groups' stigma sentiments and self-identities.

Results

The evaluation category of self-identity and of stigma sentiment were correlated in the schizophrenia group, r(88)= .44, p<.001, but not in the control group. Current symptoms and the evaluation category of stigma sentiments were significant predictors of the evaluation category of self-identity in the schizophrenia group. The evaluation and potency stigma sentiments reported by the two groups did not differ; the control group rated itself more favorably on evaluation and potency than did the schizophrenia group.

Conclusions and Implications for Practice

Self-evaluation of individuals with schizophrenia was less favorable than self-evaluation of individuals with no psychosis history, and evaluation attitudes held by individuals with schizophrenia regarding the schizophrenia label were associated with their self-identity. Results suggest preliminary utility of this simple measure in identifying self-stigma experienced by individuals with schizophrenia.

Keywords: stigma, serious mental illness, internalized stigma, self-stigma

Introduction

Individuals diagnosed with schizophrenia experience stigma, prejudice, and discrimination due to being diagnosed with a psychiatric disorder (Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002). In addition to these negative experiences, extensive research suggests that the internalization of stigmatizing messages has a pernicious effect on the well-being and recovery of individuals with mental health conditions. Self-stigma (or internalized stigma) for mental illness occurs when people with a mental health diagnosis apply negative societal messages about people with mental illness to themselves, thus believing that these negative attributes are true of themselves. In a meta-analysis by Livingston and Boyd (2010), self-stigma was related to a multitude of negative psychosocial and clinical outcomes, including reduced hope, low self-esteem, diminished quality of life, and poor treatment adherence.

The social-cognitive model of self-stigma suggests that the internalizing of stigmatizing messages is a multi-stage process, composed of stereotype awareness, stereotype agreement, and self-concurrence (Rusch, Corrigan, Powell, Rajah, Olschewski, Wilkniss, & Batia, 2009; Rusch, Corrigan, Wassel, Michaels, Olschewski, Wilkniss, & Batia, 2009; Watson, Corrigan, Larson, & Sells, 2007). “Stereotype awareness” is the result of an individual's exposure to and consciousness of stigmatizing messages in society. When faced with these stereotypes, an individual may come to believe in their accuracy; this is called “stereotype agreement.” Finally, when the individual receives a mental health diagnosis and/or identifies as a person with a mental health condition, these stereotypes become personally relevant. This puts the person at risk for “self-concurrence,” or believing that the stigmatizing attitudes are true of him/herself. This is self-stigma.

Several measures have been developed to gauge self-reported cognitive, emotional, and behavioral manifestations of self-stigma (Brohan, Slade, Clement, & Thornicroft, 2010). For example, the Internalized Stigma for Mental Illness (ISMI) Scale asks respondents to agree or disagree with statements such as, “I can't contribute anything to society because I have a mental illness.” (Ritsher, Otilingram, & Grajales, 2003). When measured in this way, self-stigma is associated with a multitude of harmful outcomes (Livingston & Boyd, 2010). While of great utility, these measures only identify the existence and impact of self-stigma in individuals who are aware that their beliefs about people with mental illness have affected their self-concept and behaviors. Emerging research suggests that a person's implicit, rather than conscious, agreement with stereotypes about a group they themselves belong to can have a negative impact on quality of life as well (Rusch, Corrigan, Todd, & Bodenhausen, 2010). Thus, assisting individuals in recognizing self-stigma could be of great clinical use in combatting its negative effects.

Another approach to assessing self-stigma involves asking people to rate the attitudes they hold towards individuals with mental health diagnoses (stigma sentiments) and towards themselves (self-identity). One measure using this technique is the Semantic Differentials Scale (SDS; Kroska & Harkness, 2006). The SDS assesses stigma sentiments and self-identity on the three universal dimensions of attitudes toward self and others, as identified by Osgood's cross-cultural research (1975): evaluation, potency, and activity. Evaluation refers to ratings of a person as good and nice, as opposed to bad and awful. Potency is defined as one's level of power versus powerlessness. Activity refers to ratings of a person as fast and active, or slow and passive. The SDS can be used to assess the constructs outlined in the social cognitive model for self-stigma. Endorsement of stigma sentiments is a reflection of the “stereotype agreement” stage of the model. Self-identity is the attitude the individual holds toward him/herself. By measuring the correspondence between stigma sentiments and self-identity, “self-concurrence” can be assessed.

Semantic differentials have been widely used in sociological research to measure attitudes and judgments (Schröder & Thagard, 2013), have been used to measure societal stigma (Link, Yang, Phelan, & Collins, 2004), and are parsimonious. Furthermore, research indicates that evaluative, potency, and activity characteristics are understood similarly across cultures (Osgood et al., 1975). Because the SDS contains simple, cross-culturally valid constructs, it is unlikely to be interpreted idiosyncratically by respondents (Kroska & Harkness, 2006). In addition, Kroska and Harkness (2006) demonstrated the construct validity of the SDS, finding that a) individuals' evaluation and potency ratings of a mentally ill person were related to the Devaluation-Discrimination Index (Link, 1987), b) attitudes towards “a mentally ill person” were positively correlated with devalued categories (e.g., “outcast”), and c) attitudes towards “a mentally ill person” were negatively associated with respected identities (e.g., “doctor”, “hero”) (Kroska & Harkness, 2006). Finally, this approach enables comparisons of stigma sentiments (i.e., stereotype agreement) and self-identity between members and non-members of stigmatized groups, an added advantage over most measures of self-stigma.

However, replication and further refinement of previous research is needed. First, studies using the SDS used Global Assessment of Functioning (GAF; APA, 1994) scores to assess the relationships among stigma sentiments, self-identity, and symptom severity, rather than employing a true measure of symptoms (Kroska & Harkness, 2006; Kroska & Harkness, 2008). The relationship of symptom severity with both self-stigma and self-identity is well-supported in the literature (Livingston & Boyd, 2010) and may be a confounding factor when measuring the relationship between these constructs. Failure to account for symptom severity may prohibit a valid assessment of self-concurrence.

Second, differences in stigma sentiments between people with versus without a schizophrenia diagnosis have not yet been explored; this could (1) clarify whether individuals with schizophrenia have more extreme stigmatizing attitudes regarding schizophrenia than do individuals without the disorder, and (2) validate the use of the SDS as a measure of self-stigma within this population. Analyses demonstrating a relationship between stigma sentiments and self-identity in a group of individuals without the disorder would indicate that this is not a valid measure of self-stigma.

Finally, one of the two studies using the SDS investigated associations between stigma sentiments towards the category “a mentally ill person” and self-identity among people diagnosed with affective disorders, adjustment disorders, and schizophrenia spectrum disorders (Kroska & Harkness, 2008). Most of these analyses were conducted with the full sample and the diagnosis-specific analyses employed a liberal standard for statistical significance of findings. Although authors did not find an association between stigma sentiments and self-identity among those with schizophrenia, their sample within this diagnostic group was small (n=17). Because there is some evidence that societal stigmas vary according to mental health diagnosis (Reavley & Jorm, 2011), a larger, more diagnostically-uniform sample and a diagnostically-specific stigma sentiment measure will provide a more precise analysis of self-stigma experienced by individuals with schizophrenia disorders.

The present study used the SDS to investigate the stigma sentiments and self-identity of individuals with schizophrenia or schizoaffective disorder and a group with no psychosis history. Our primary hypothesis was that the schizophrenia group would show self-concurrence, such that attitudes about the evaluation, potency, and activity of individuals with schizophrenia (stigma sentiments) would positively correlate with these attitudes towards the self (self-identity). Exploratory analyses tested whether this relationship between stigma sentiments and self-identity exists in individuals with no schizophrenia diagnosis. Because of the potential confounding effect of symptomology on self-stigma (Livingston & Boyd, 2010), we tested a model that includes functioning, symptoms, and mental illness stigma to predict self-identity in individuals with schizophrenia. We hypothesized that stigma sentiments would remain a significant predictor of self-identity when both symptom severity and functioning are taken into account. In addition, we hypothesized that the attitudes reported towards “a person with schizophrenia or schizoaffective disorder” would be unfavorable by all participants, demonstrating stereotype agreement. We also predicted that individuals with schizophrenia would report a less favorable self-identity than would controls.

Method

Participants and Data Collection

The sample in the present study was composed of two groups: individuals with schizophrenia or schizoaffective disorder and controls with no psychosis history. Data for all participants were collected for a larger study of cognition and language in schizophrenia (author, 2012). Participants were excluded if they had mental retardation or current substance abuse; they also could not have a history of seizures, inhalant use, brain injury, or drug or alcohol dependence requiring inpatient detoxification.

Schizophrenia group

All participants in the schizophrenia group were receiving outpatient treatment at community mental health centers in Akron, Ohio, and were stable psychiatrically. Participants met criteria for a DSM-IV-TR diagnosis of schizophrenia or schizoaffective disorder as determined with the Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978) modified slightly for use with DSM-IV-TR.

Control group

Control participants were community members recruited from the Akron, Ohio area by means of flyers placed in churches, community centers, social service agencies, and throughout a college campus. Control participants could not have a history of psychotic symptoms, as determined through administration of the SADS. A history of non-psychotic mental health conditions was not an exclusion criterion.

Data collection

All potential participants took part in a standardized informed consent process with trained recruiters. Any participants unable or unwilling to complete the consent process were not included in the study. Each participant was administered a four-hour assessment battery over a two-day period. All research interviewers were clinical psychology graduate students with appropriate backgrounds in the study of psychosis. Clinical interviewers were trained by a licensed clinical psychologist, using reading materials, training tapes, and live supervision. Ongoing inter-rater reliability was maintained by obtaining consensus on ratings of participant symptom severity. Diagnoses were confirmed under the supervision of a licensed clinical psychologist.

All assessments and procedures were reviewed and approved by the Kent State University Institutional Review Board.

Study sample

Participants in the schizophrenia group were 90 individuals with DSM-IV-TR diagnoses of either schizophrenia (n=43) or schizoaffective disorder (n=47). There were no significant demographic or clinical differences between the schizophrenia and schizoaffective disorder subgroups, nor did their scores on the SDS scale differ; thus, they are thus treated as one group in all analyses. The control group was composed of 23 participants. See Table 1 for demographic data and comparisons between groups.

Table 1. Demographic and clinical data, with group comparisons (n=113).
Demographic and Clinical Variables Schizophrenia
(n = 90)		 Control Group
(n = 23)		 χ2 t p
Mean age in years (SD) 39.27 (7.16) 37.65 (9.13) .911 .365
% female 45.6 (41/90) 47.8 (11/23) .038 .845
% African American 55.6 (50/90) 34.8 (8/23) 3.77 .152
% Caucasian 31.1 (28/90) 39.1 (9/23)
% All other 13.3 (12/90) 26.1 (6/23)
Mean years of education, (SD) 11.58 (1.83) 15.13 (2.24) -7.889 .000
Years of parents' education (SD) 12.41 (3.01) 12.35 (1.43) .143 .887
Mean PANSS Total Score (SD) 68.25 (17.67) __ __ __
Mean GAF (SD) 48.19 (13.03) __
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Significant group differences (p<.05) are in bold.

Three individuals from the larger dataset (author, 2012) were excluded from the present study because of incomplete or absent information on the primary measure of interest, the Semantic Differentials Scale, and 24 were excluded because they did not meet diagnostic criteria for the present study.

Assessment Measures

Psychiatric Symptoms

Current (past week) psychiatric symptoms were established with the Positive and Negative Syndrome Scale (PANSS; Opler, Kay, Lindenmayer, & Fiszbein, 1986). The PANSS is a widely-used symptom rating interview, which includes 30 items rated by the interviewer on a scale of 1 (absent) to 7 (extreme). The PANSS has demonstrated acceptable stability and reliability, as well as criterion and predictive validity, for use with individuals with schizophrenia (Kay, Fiszbein, & Opler, 1987). The intraclass correlation for the full scale score was .96. The PANSS was conducted only with participants in the schizophrenia group.

Global Functioning

The Global Assessment of Functioning (GAF) scale was used to rate current overall symptom severity and level of functioning (APA, 1994). The GAF scale is divided into 10 ranges of functioning with a possible score of 1-100. A high GAF score indicates good overall functioning. GAF scores were determined only for the schizophrenia group, based on information obtained during the SADS and PANSS assessments. GAF scores were determined under the supervision of a licensed clinical psychologist.

Semantic Differentials Scale (SDS; Kroska & Harkness, 2006; Osgood et al., 1975)

This brief questionnaire measures participant affective appraisals of self-identity (“Myself as I really am”), reflected appraisal (“Myself as others see me”), stigma sentiments (“A person with schizophrenia or schizoaffective disorder,” and “A person with bipolar disorder”), and aspirational self (“Myself as I should be”). For each of these categories, participants were asked to provide evaluation, potency, and activity scores using nine-point scales. The evaluation scale was anchored with the adjective pairs “good, nice” and “bad, awful,” the potency scale with “powerful, big” and “powerless, little,” and the activity scale with “fast, noisy, young” and “slow, quiet, old.” The middle circle was marked “neutral”; the circles between the midpoint and the endpoints were marked with “slightly,” “quite,” “extremely,” and “infinitely.” These were coded with values ranging from 1 to 9. To reduce response bias effects, the direction of the adjective valence was counterbalanced and reverse coded as appropriate. The SDS has demonstrated construct validity in a study including individuals with and individuals without a diagnosed mental health condition (Kroska & Harkness, 2006).

There are six total SDS variables included in this study, which are labelled as follows: self-identity/evaluation, self-identity/potency, self-identity/activity, stigma sentiment/evaluation, stigma sentiment/potency, and stigma sentiment/activity.

Data Analysis

Independent t-tests and chi-square analyses were used to compare the two groups on demographics (gender, age, race/ethnicity, years of education, parent years of education) and the six SDS variables (evaluation, potency, and activity ratings for both self-identity and stigma sentiment for schizophrenia). The Welch's t-test was used when heterogeneity of variance between diagnosis groups were present; this is an appropriate statistical correction in the case of unequal sample sizes with t-tests (Howell, 2002). Pearson product moment correlations were used to assess the relationship between self-identity and stigma sentiments for the schizophrenia and control samples.

Because bivariate correlations indicated a significant relationship between stigma sentiments and self-identity for the evaluation dimension, a linear regression model was used to determine if evaluation stigma sentiment had a unique contribution to the prediction of evaluation self-identity when current symptom severity (PANSS total score) and psychosocial functioning (GAF) were also used as predictors. No demographic variables were significantly associated with evaluation self-identity; therefore, they were not included in the linear regression model.

Results

Preliminary Analyses

See Table 1 for demographic data for both groups. In the schizophrenia group, the mean GAF score (M=48.19, SD=13.03) was in the “serious symptoms, or any serious impairment in social, occupational, or school functioning” range (APA, 1994), and the mean PANSS score (M=68.25, SD=17.67) was in the “mildly to moderately ill” range (Leucht, Kane, Kissling, Hamann, Etschel, & Engel, 2005). See Table 2 for means and standard deviations for the SDS for both groups. The possible range of scores for each SDS item was 1-9, with a score of five corresponding to a response of “neutral.” Scores above five indicated a response of more “good, nice” on evaluation variables, a response of more “powerful, big” for the potency variables, and more “fast, noisy, young” for activity variables. Mean scores on stigma sentiment variables ranged from 4.37 to 5.49; mean scores on self-identity variables ranged from 4.66 to 7.22.

Table 2. Between-group comparisons of stigma sentiments and self-identity ratings (n=113).

Schizophrenia Group
(n=90)		 Control Group
(n=23)		 T-test result P value
Stigma Sentiment (Evaluation), mean (sd) 5.49 (2.42) 5.26 (1.63) 0.54 p=.59
Stigma Sentiment (Potency), mean (sd) 4.81 (2.59) 4.61 (1.59) 0.47 p=.64
Stigma Sentiment (Activity), mean (sd) 4.37 (2.26) 5.17 (1.19) -2.35 p=.02
Self-identity (Evaluation), mean (sd) 6.18 (2.45) 7.22 (1.35) -2.72 p=.008
Self-identity (Potency), mean (sd) 4.76 (2.35) 6.65 (1.56) -3.66 p=.000
Self-identity (Activity), mean (sd) 4.66 (2.32) 5.43 (1.85) -1.49 p=.14
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Stigma Sentiment = attitudes towards “A person with schizophrenia or schizoaffective disorder”, Self-identity = attitudes towards “Myself as I really am”

A score of 5 =“Neutral”

Significant group differences (p<.05) are in bold.

In the schizophrenia group, no significant associations were found between SDS variables and participant or parent education, nor were there any gender or race/ethnicity differences on the SDS variables. Age was significantly, negatively associated with self-identity/potency, r(86)= -.36, p<.001, meaning that older age corresponded with beliefs of being less powerful. The PANSS total score was associated with several SDS variables, including self-identity/evaluation, r(88)= -.38, p<.001, self-identity/activity, r(88)= -.30, p<.01, and stigma sentiments/evaluation, r(88)= -.26, p<.05. GAF score was significantly associated with self-identity/potency, r(87)= .32, p<.01, and self-identity/activity, r(87)= .22, p<.05.

In the control group, education was significantly, positively associated with stigma sentiments/evaluation, r(21)= .49, p<.05, meaning that more education corresponded with more favorable views of individuals with schizophrenia disorders. No other associations between demographic and SDS variables were significant in the control group.

Self-Identity and Stigma Sentiments

See Table 2 for means, standard deviations, and between-group comparisons on the six SDS variables. People with schizophrenia were significantly more variable in their responses to all three stigma sentiments and in self-identity/evaluation, when compared with people without schizophrenia. Results indicate no significant differences in stigma sentiments/evaluation or potency between the schizophrenia group and controls; stigma sentiment/activity was significantly lower in the schizophrenia group. Self-identity/evaluation and self-identity/potency ratings were significantly lower in the schizophrenia group versus the control group; there were no significant group differences on self-identity/activity. When education was entered as a covariate, between-group results for stigma sentiment/activity, F(1,109)= 2.00, p=0.16, and self-identity/evaluation, F(1,109)= 2.98, p=0.09 were no longer significant. Other between-group results remained essentially unchanged.

In the schizophrenia group, the self-identity/evaluation and stigma sentiment/evaluation scores were correlated, r(88)= .44, p<.001. Self-identity/potency was not significantly associated with stigma sentiment/potency, r(88)= .20, p=.06, nor was self-identity/activity associated with stigma sentiment/activity, r(88)= .17, p=.10.

A Pearson product moment correlation was conducted to test whether the significant association between self-identity/evaluation and stigma sentiment/evaluation in the schizophrenia group was also present in the control group; the correlation was non-significant, r(21)= .01, p=.95.

Regression Model Predicting Self-Identity in the Schizophrenia Sample

A regression analysis tested a model predicting self-identity/evaluation in the sample of individuals with schizophrenia, using current symptom severity (PANSS score), psychosocial functioning (GAF), and stigma sentiment/evaluation. Because there were no significant associations between stigma sentiments and self-identity for the potency or activity variables, no regressions were performed involving these categories.

The overall model was a significant predictor of self-identity/evaluation, R2= 0.269, F(3, 85)=10.433, p<.001. As shown in Table 3, stigma sentiment/evaluation and PANSS score were both significant predictors of self-identity/evaluation.

Table 3. Predictors of self-identity/evaluation in the schizophrenia sample (n = 90).

b SE t P CI (95%)
Intercept 6.557 1.858
Stigma sentiment/evaluation .364 .097 3.736 .000 .170-.557
PANSS total score -.039 .015 -2.564 .012 -.069 - -.009
GAF .005 .020 .253 .801 -.034 - .044
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Significant results (p<.05) are listed in bold.

Discussion

This study found that the schizophrenia group's assessment of their own goodness was significantly and positively associated with their assessment of the goodness of “a person with schizophrenia or schizoaffective disorder.” This relationship was still significant when current symptom severity and overall functioning were taken into account. It may be that a person diagnosed with schizophrenia who does not believe the stigmatizing messages related to the diagnosis may experience less of a negative impact on self-identity. Similarly, if a person accepts the schizophrenia label and also continues to think of themselves as a good person, they may also begin to see people with schizophrenia as good. Additionally, there was no association between self-identity/evaluation and stigma sentiment/evaluation in the control group. This counters the possibility that an association between stigma sentiment and self-identity is due to a confounding bias whereby one's general positive (or negative) outlook would lead to similar scores in both categories. Clinicians must be mindful that global evaluations about people with schizophrenia are closely aligned with self-identity in this population.

Of the three categories of attitudes assessed in this study, only evaluation (good/bad) of individuals with schizophrenia was associated with self-identity in the schizophrenia group. One explanation is that perceived goodness/badness of a group or of an individual is an unequivocal assessment of worth in ways that power and activity are not, and thus may be more salient for a person placed in a stigmatized group. Thus, the evaluation construct maps most closely onto stigma towards individuals with schizophrenia and may be the most internalized of the three dimensions. Furthermore, individuals with schizophrenia may be less likely to reference cultural attitudes towards schizophrenia in order to characterize their own activity and potency, as these dimensions are less static over time and context than goodness/badness of an individual or group.

There are three possible explanations for the relationship between stigma sentiment/evaluation and self-identity/evaluation. The first is the social-cognitive theory of self-stigma (Watson et al., 2007); when a person is assigned a mental health diagnosis, he/she may apply prior-held stereotypes about mental illness to themselves, resulting in self-stigma. Applying this framework to our results, 1) the individual holds attitudes towards schizophrenia that are similar to others in his/her culture (stereotype agreement); 2a) the individual is given the mental illness label; and 2b) experiences psychiatric symptoms that also affect his/her self-evaluation; resulting in 3) the belief that the cultural attitudes towards individuals with schizophrenia apply to him/her (self-concurrence).

The second interpretation posits that people with schizophrenia developed their attitudes towards people with schizophrenia based on their self-identity. In this interpretation, individuals with schizophrenia 1) develop a negative self-identity for reasons not identified in this study; 2) then associate this negative self-identity with the schizophrenia diagnosis; and 3) finally hold negative attitudes towards individuals with schizophrenia as a group. However, the schizophrenia group had stigma sentiments similar to individuals in their culture who do not have the diagnosis, suggesting that the schizophrenia group held these stigmatizing attitudes prior to receiving a schizophrenia diagnosis. Other research on the ubiquity of mental illness stigma in the US supports this interpretation (Parcesepe & Cabassa, 2013), making it unlikely that these attitudes developed only after receiving a diagnosis.

A third interpretation is that individuals with schizophrenia suffer from less favorable self-identity primarily due to symptoms associated with the disorder and that their opinion of others with schizophrenia stems from their own experience with these symptoms. Results do suggest that current symptoms are associated with self-identity and stigma sentiments; however, the regression analysis presents evidence for stigma sentiments as predictors of individuals' self-identity beyond their symptoms. Thus, the present study supports the social-cognitive model of self-stigma, with additional impact on self-identity related to symptoms.

Contrary to study hypotheses, neither group reported an unfavorable view of individuals with schizophrenia; rather, stigma sentiment scores were approximately neutral. Prior research on the SDS has found similar results (Kroska & Harkness, 2006), suggesting that these neutral responses are not necessarily unique to our sample and warrant further investigation. The SDS measures self-stigma not as an absolute value, but as the strength of the relationship between stigma sentiments and self-identity scores. Within that context, although most scores were at neutral, any shifts away from “neutral” are closely tied with self-identity (r=.44) among those with schizophrenia. Future research should explore whether participants' sentiments towards people who do not have mental illness are comparable to those outlined here (e.g., while those with schizophrenia are rated as neutral, those without mental illness may be rated even more favorably).

Results for the present study provide evidence of preliminary validity for the SDS as a measure of self-stigma for individuals with schizophrenia. Clinically, the evaluation component of this simple, brief, and easily-administered measure can be used with individuals experiencing feelings of low self-worth to identify a possible role of stigma in these feelings. An additional advantage of this measure is that, unlike many other existing measures of self-stigma, it does not include negatively-valenced, stigmatizing statements about individuals with mental health diagnoses and thus may be less potentially provocative for respondents. The next step in assessing this measure's incremental utility for stigma research is to explore its correspondence to more widely used measures of self-stigma (e.g., the ISMI; Ritsher, Otilingram, & Grajales, 2003) and to implicit measures of self-stigma (e.g., the Implicit Association Task; Rusch et al., 2010), to examine whether this measure is sensitive to the presence of self-stigma in individuals who are not aware of stigma's impact on their own self-identity. In addition, measuring stigma sentiments towards other stigmatized groupings (non-white race, female gender, etc.) may further test the validity of this measure.

Limitations

Although the primary hypotheses involve the substantially larger schizophrenia group, we acknowledge that analyses involving the control group by itself were somewhat underpowered due to small sample size. Because the study did not exclude individuals from the control group who had a history of non-psychotic mental health disorders, between-group differences on self-identity may have been attenuated, to the extent that control participants' self-identity was impacted by stigma for their non-psychotic mental health condition. Future research should compare larger samples of individuals with and without mental illness to those with schizophrenia to further validate the specificity of this measure for detecting self-concurrence among people with mental illness.

While the simple, straightforward content of the SDS is a strength, making it relatively easy to understand (Kroska & Harkness, 2006), SDS categories are quite general and cannot provide a more fine-grained characterization of the evaluative attitudes held by respondents. It is possible that more detailed stigma sentiments would reflect stronger endorsement of schizophrenia stereotypes. Finally, we must acknowledge the possibility that social desirability affected the validity of respondents' reports of stigma sentiment. Considered together, these limitations highlight the preliminary nature of the study findings. Further research on this measure is warranted.

Conclusion and Implications

Among people with schizophrenia, self-identity and stigma sentiments are related; beliefs about their fundamental goodness or badness were related to their beliefs about people with the disorder. These results add further support to a growing recognition of the pernicious impact of societal stigma on the self-concept of individuals with schizophrenia. The results of this study are consistent with a Recovery-based approach, in which positive self-regard and well-being are affected by more than just symptom reduction. Interventions that teach strategies for challenging mental illness stereotypes and for fortifying favorable self-identity show promise in reducing self-stigma and its negative effects (Mittal, Sullivan, Chekuri, Alee, & Corrigan, 2012), thereby improving the lives of individuals diagnosed with mental health conditions.

Acknowledgments

Preparation of this article was supported in part by the National Institutes of Mental Health grant R01-MH58783 to Dr. Docherty; the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs; and the VA Capitol Health Care Network VISN 5 Mental Illness Research, Education, and Clinical Center. The funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

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