Since ancient times, when mental illness
was connected to “evil spirits” and demonic possession, people suffering from mental illness have faced public stigma. In modern societies, despite advances in the treatment of the mentally ill, psychiatric disorders are still viewed as congenital, untreatable, a sign of personal weakness, uncontrollable and dangerous, despite the fact that less than 3% of mentally ill patients could be categorized as dangerous [1
]. Many factors play their part in the persistence of stigma against the mentally ill: the possibility of peculiar and bizarre behaviour which is both undesirable and inconsistent with social norms; the risk of unpredictable behaviour as a result of “being out of one’s mind”; the risk of suicide and self-injury; the sensationalism by the mass media in its portrayal of the mentally ill; resistance to psychiatric therapy which is sometimes considered no different to “brainwashing”; the devastating effects of psychosis manifested through functional impairments; and family stigmatization whereby mental illness is seen as “running in the family as a result of bad genes”.
There are many different ways in which the general public stigmatizes people with mental illness, and these include labelling, stereotyping, separation, discrimination, etc. Public stigma frequently results in self-stigma as “The product of internalization of shame, blame, hopelessness, guilt and fear of discrimination associated with mental illness” (To experience self-stigma a person must be aware of the stereotypes that describe a stigmatized group of people with mental illness (e.g., “People with mental illness are unpredictable and dangerous”), agree with them (“That’s right, people with mental illness are unpredictable and dangerous to other people”), and apply stereotypes to themselves (“I am mentally ill, so I must be dangerous to other people”). These forms the “three A’s” of the self-stigmatization process: awareness, agreement, and application [2
]. Research suggests that self–stigma leads to decreased self-esteem
, depression, delayed seeking of treatment, prolonged course of illness, poor outcome, social withdrawal, reduced self-efficacy and worsening of quality of life [3
It is well documented that people with severe mental illness (e.g., schizophrenia, bipolar disorder) are those who are the most troubled by public and internalized stigma [13
], but there is a scant data on stigma associated with less severe forms of mental disorders. In our study, we have chosen to research internalized stigma in panic disorder
patients who face sudden, unexpected panic attacks, one of the most unpleasant emotional experiences, with a a range of significant physiological and cognitive symptoms. The physical symptoms of panic attacks make some patients believe deeply that they have a life–threatening illness and that their very physical survival is in question, particularly in those with chest pains or with comorbid cardiovascular disease. With each new panic attack, they often expect disaster to occur – leading to a “life with fear” and a “life in fear”. Research indicates that the prevalence of panic disorder among cardiology outpatients, and patients with documented coronary artery disease, ranges between 10% and 50% [15
]. Patients with comorbid coronary ischemic disease and panic disorder may really be at increased cardiac risk as panic attacks increase coronary vasomotor tone, an important component of sympathetic hyperactivity, setting off an increase in myocardial oxygen consumption [16
]. The difficulty in distinguishing between chest pains due to psychogenic and organic causes can lead to patients living on the "edge," with a sense of having no control over their own lives – this in turn can lead to demoralization and depression. Some patients, especially those with symptoms of depersonalization and derealisation, suffer from significant phrenophobia – the fear of insanity, and they can suffer for a long time in secret, avoiding psychiatric consultation because they fear the psychiatrist might diagnose "their madness." They are afraid of ending up in a mental institution, of being "stigmatized", of the possibility of behaving unpredictably, of being rejected, of losing social status and of embarrassing their families. Many fear that others will see their symptoms and judge them as unstable and fragile. Also, some patients with panic disorder are at risk of developing agoraphobia with incapacitating symptoms such as avoiding public places and crowds. In the most severe cases, this can leave them housebound, as the house is the only place where they feel they can tolerate their anxiety. People who cannot independently go into the street, go shopping, go to the dentist or hairdresser, or take their children to school, and who depend on other people to help with day-to-day activities, over time demoralize, lose self-esteem, experience helplessness and become secondarily depressed. Some of them feel disappointed when, after a number of somatic examinations, they are diagnosed with a mental disorder, which receives less sympathy and protection from those they love, feeling that mental illness is seen as a weakness and a defect of personality. All of these facts could influence self-esteem in patients with panic disorder and result in internalization of negative stereotypes about mentally ill people. This could further lead to depression and vice-versa, social withdrawal and decrease in quality of life. We hypothesized that panic disorder patients (with/without agoraphobia) experience internalized stigma, and this experience of self-stigma is negatively correlated with self-esteem and quality of life, and positively correlated with depression.