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Neuropsychiatric Disease and Treatment 2016:12 2439–2448
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ORIGINAL RESEARCH
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/NDT.S114671
Self-stigma in borderline personality disorder –
cross-sectional comparison with schizophrenia
spectrum disorder, major depressive disorder,
and anxiety disorders
Ales Grambal1
Jan Prasko1
Dana Kamaradova1
Klara Latalova1
Michaela Holubova1,2
Marketa Marackova1
Marie Ociskova1
Milos Slepecky3
1Faculty of Medicine and Dentistry,
Department of Psychiatry, Palacky
University Olomouc, University
Hospital Olomouc, Olomouc,
2Department of Psychiatry, Hospital
Liberec, Liberec, Czech Republic;
3Faculty of Social Science and Health
Care, De partmen t of Psychology
Sciences, Constantine the Philosopher
University, Nitra, Slovak Republic
Introduction: Self-stigma arises from one’s acceptance of societal prejudices and is common
in psychiatric patients. This investigation compares the self-stigma of a sample of patients
with borderline personality disorder (BPD), schizophrenia spectrum disorder (SCH), major
depressive disorder (MDD), bipolar affective disorder (BAD), and anxiety disorders (AD) and
explores of the self-stigma with the subjective and objective measures of the severity of the
disorder and demographic factors.
Methods: The total of 184 inpatients admitted to the psychotherapeutic department diag-
nosed with BPD, SCH, MDD, BAP, and AD were compared on the internalized stigma of
mental illness (ISMI) scale. The ISMI-total score was correlated with the subjective and
objective evaluation of the disorder severity (clinical global impression), and clinical and
demographic factors.
Results: The self-stigma levels were statistically significantly different among the diag-
nostic groups (BPD 71.15±14.74; SCH 63.2±13.27; MDD 64.09±12.2; BAD 62.0±14.21;
AD 57.62±15.85; one-way analysis of variance: F=8.698, df=183; P,0.005). However after
applying the Bonferroni’s multiple comparison test, the only significant difference was between
the BPD patients and the patients with AD (P,0.001). Stepwise regression analysis showed
that the strongest factors connected with the higher level of self-stigma were being without
partner, the number of hospitalization, and the severity of the disorder.
Conclusion: The BPD patients suffer from a higher level of self-stigma compared to patients
with AD. In practice, it is necessary to address the reduction of self-stigma by using specific
treatment strategies, such as cognitive therapy.
Keywords: self-stigma, borderline personality disorder, schizophrenia spectrum and related
disorders, major depressive disorder, anxiety disorders, severity of the disorder
Introduction
Self-stigma is a maladaptive process in which individuals accept societal prejudices
and integrate this evaluation into their self-concept.1 Persons suffering from psychi-
atric disorders may be principally vulnerable to the self-stigma. Self-stigmatization
can be understood as a series of stages:2 1) persons becoming conscious of societal
labels; 2) agree with the labels; 3) apply the labels to themselves; and 4) subsequently
suffering lower self-esteem.
According to a meta-analysis by Livingston and Boyd, self-stigma is associated with
the lower quality of life, levels of hope, self-esteem, self-efficacy, empowerment, social
Correspondence: Jan Prasko
Faculty of Medicine and Dentistry,
Department of Psychiatry, Palacky
University Olomouc, University Hospital
Olomouc, IP Pavlova 6, 77520 Olomouc,
Czech Republic
Tel +420 588 443 519
Email praskojan@seznam.cz
Journal name: Neuropsychiatric Disease and Treatment
Article Designation: Original Research
Year: 2016
Volume: 12
Running head verso: Grambal et al
Running head recto: Self-stigma in borderline personality disorder
DOI: http://dx.doi.org/10.2147/NDT.S114671
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support, and higher severity of psychiatric symptomatology.1
Additionally, higher self-stigma is connected with lower
functioning in social and work situations.3,4 Social malad-
aptation (especially social isolation) related to self-stigma
results in further discrimination, which perpetuates a vicious
circle of social stigma, self-stigma, and social maladaptation.5
Finally, self-stigma is correlated with the suicidality and with
a history of suicide attempts.6,7 However, it is important to
note, that associations between level of self-stigma and dif-
ferent variables are of correlational nature and thus do not
indicate causal effects.
Patients with borderline personality disorder (BPD)
expect and perceive social rejection stronger than the general
population.8 They also show negative and unstable self- and
other evaluations compared to healthy individuals.9,10 Both
could be connected with higher level of self-stigma in this
group of patients. Persistent problems in social interactions, as
well as intense and unstable interpersonal relations, and exag-
gerated efforts to avoid abandonment describe core features
of BPD.11–13 Studies report that individuals with a personality
disorder, especially with BPD, stigmatize themselves more
than persons without a personality disorder.14–17
The comprehensive model regarding how self-stigma
affects function in patients with severe mental illness (SMI)
was published by Yanos et al.18 It may be helpful also to the
understanding of this process in BPD. By empirical data,
they proposed two models. Consequences from model 1
reinforced the view that internalized stigma increase avoidant
coping, active social avoidance, and depressive symptoms
and that these interactions are intermediated by the influence
of self-stigma on self-esteem and hope. Consequences from
model 2 replicated relevant associations from model 1 but
also reinforced the hypothesis that positive symptoms can
affect hope and self-esteem. Conclusions from two models
reinforced the assumption that self-stigma affects self-esteem
and hope, leading to negative consequences associated with
recovery. Global self-esteem among persons with SMI may
be negatively affected by stigma or stereotyped beliefs about
individuals with SMI.19 According to Lysaker et al,20 features
of self-esteem related to lovability by others were closely
connected with reduced feelings of being alienated from
others due to psychiatric disorder. Features of self-esteem
linked to the capability to manage one’s businesses were
more strictly related to the rejection of stereotypes of mental
illness. A feeling of being capable of influencing others was
related to both the absence of discrimination experiences and
the ability to ward off the stigma. The possibility that internal-
ized stigma and deficits in social cognition and metacognition
in schizophrenia spectrum disorder (SCH) are risk factors for
insight to convert to depression was tested by Lysaker et al.21
Patients with SCH with good insight and moderate depres-
sion reported more internalized stigma than those with poor
insight and minimal depression. Patients with real insight
and mild depression had higher levels of social cognition and
metacognitive mastery than the other two groups.
While self-stigma is common in BPD, only a few studies
have reported the investigation focusing on the comparison
of the level of stigma in BDP patients with another diagnos-
tic subgroup like psychosis, affective disorders or anxiety
disorders (AD). Using the self-report questionnaires, Rüsch
et al14 assessed the self-stigma in 60 females with BPD and
30 females with social phobia. Self-stigma was inversely
related to the quality of life, self-efficacy, and self-esteem.
Females with social phobia displayed lower self-stigma
than females with BPD. This could reflect strong labeling
processes as being mentally ill due to many interpersonal
difficulties, repeated hospitalizations, and possibly visible
scars. Ociskova et al16 showed that the average of internalized
stigma of mental illness (ISMI) scale score was statistically
higher in the patients with an anxiety disorder and a comorbid
personality disorder compared to the patients without this
comorbidity (especially in the ISMI subscales alienation and
percieved discrimination).
The aim of our study was to investigate the self-stigma
in patients with BPD and compare it with the self-stigma
in patients with SCH, major depressive disorder (MDD),
BAD, and AD. The second aim was to study the relation
between self-stigma, demographic characteristics, and the
severity of the disorder. Understanding the relationship
between self-stigma and clinical and demographic correlates
may inform about interventions to reduce the self-stigma in
high-risk subgroups. Being able to characterize a patient’s
self-stigma can help in treatment planning, which is reflected
in the emerging literature on interventions to address
self-stigma.1,4,22–24
We prepared several hypotheses before beginning of the
study. They were:
(1) A self-stigma measured by ISMI-total score (TS) will be
higher:
(a) in patients with BDP in comparison with patients with
adjustment disorder;
(b) in patients in whom the problems started earlier in
their life;
(c) in patients with higher level of psychopathology;
(d) in less educated patients;
(e) in patients with more psychiatric hospitalizations;
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Self-stigma in borderline personality disorder
(f) in patients without a partner;
(g) in patients without a job.
(2) The self-stigma of patients with BDP measured by
ISMI-TS will be equal with the self-stigma of patients
with SCH, bipolar disorder, and MDD.
(3) The domain stigma resistance will be lower in patients
with BDP than in other diagnostic groups.
Methods
Participants were recruited from outpatients of the Psycho-
therapeutic Psychiatric Department of University Hospital
Olomouc in the period from July 1, 2014 to October 31, 2014.
Then, the patients were screened for eligibility by the outpa-
tient psychiatrists. The inclusion criteria were as follows:
(1) BPD, SCH, MDD, BAD, and AD according to Interna-
tional Classification of Diseases-10 research diagnostic
criteria.25
(2) the age of 18–60 years.
(3) both sexes.
Exclusion criteria included the inability to participate
in psychiatric interviews or give informed consent, the
age ,18 or .60 years, being at immediate risk of suicide,
actual or chronic serious somatic disorder, organic brain
disease, and subnormal intelligence.
Including criteria were confirmed by the clinical interview
of two experienced psychiatrists. The structured clinical
interview, such as the severe combined immunodeficiency
was not used. Patients who have comorbid investigated
disorder, for example, comorbid BPD and MDD, was not
excluded but received “the principal diagnosis” according to
the psychiatrist, who recognize, which diagnosis had more
severe expression at the time of evaluation.
Description of the assessment tools
Internalized stigma of mental illness scale
The ISMI is a 29-item questionnaire which measures inter-
nalized stigma according to four-point Likert scale (strongly
disagree, disagree, agree, or strongly agree).26 The total scale
score ranges from 29 to 116, with 63 and 64 being the average
scores for self-stigma. The scale has five domains: alienation,
stereotype endorsement, discrimination experience, social
withdrawal, and stigma resistance. The alienation subscale
assesses the patient’s experiences of being less than a full
member of or being disqualified from society due to his or
her disorder. The stereotype endorsement subscale mea-
sures the degree to which the individual agrees with widely
accepted stereotypes about people with mental illness. The
perceived discrimination subscale is concerned with the
patient’s sensitivity to the way how other people treat him
or her supposing they know about his or her mental illness.
The social withdrawal scale was inspired by statements pro-
duced by focus group members who claimed that they avoid
interactions with others not to burden them with their mental
problems or because they fear rejection in case people around
them learn about the mental illness. The stigma resistance
subscale determines the degree to which the patient can be
unaffected by self-stigma.26 A multinational study has tested
the psychometric properties of the ISMI, finding an internal
consistency reliability of α=0.90 and a test–retest reliability
of between 0.62 and 0.90.27 The Cronbach’s alpha of the
Czech translation of the scale (α=0.91) was excellent, as well
as reliability analyzed by the split-half method (Spearman–
Brown coefficient 0.93) and test–retest 3 weeks after the first
measurement (r=0.90, P,0.001).28
Clinical global impression
Clinical global impression (CGI) is a scale used for global
assessment of the severity of psychopathology.29 We used
severity scale of CGI. It is one-item scale. The initial evalu-
ation is performed by the patient’s psychiatrist using the
objective form of the scale (CGI-O). The patient also assesses
himself/herself by the subjective version (CGI-S), which
includes seven levels of severity of the psychopathology. The
intra-class correlations lie in the interval 0.88–0.92.30
The demographic questionnaire
The demographic questionnaire contains basic information
such as sex, age, the age of disease onset, marital status,
living with partner or not, employment status, pension status,
education, the number of psychiatric hospitalizations, and
current medication.
Treatments
The antidepressant (n=132; 71.7%) were the most common
drugs used by the participants, followed by antipsychot-
ics (n=83; 45.1%), tymostabilizers (n=42; 22.8%), and
anxiolytics (n=35; 19%). The dosage of medication was in
ranges according to the guidelines of the therapy in treated
diagnostic groups. The mean dosage of antidepressant was
40.92±26.89 mg of paroxetine equivalent, in antipsychotics
4.49±13.14 mg of risperidone equivalent, and 9.92±11.65 mg
of diazepam equivalent.
Statistical analysis and ethics
The packages GraphPad Prism version 5.0 (GraphPad
Software, Inc., La Jolla, CA, USA) and the Statistical Package
for the Social Science version 24.0 (IBM Corporation, Armonk,
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Grambal et al
NY, USA) were used for statistical analyses. Descriptive sta-
tistics was applied to the demographic and clinical data. The
Shapiro–Wilk W-test determined the Gaussian distribution of
the demographic, clinical, and ISMI variables. The t-tests of
the Mann–Whitney U-tests were used for comparison of the
means. Mean ISMI, CGI-O, and CGI-S scores were calculated
as were mean and standard deviation of each ISMI subscale.
Differences between diagnostic groups were determined by
unpaired t-tests and one-way analysis of variance. Associa-
tions between factors were analyzed by Pearson’s or Spear-
man’s correlations and multiple regression. The Fisher’s exact
test or chi-square test verified the connection between alter-
native variables (sex, marital status, partnership, education,
and employment). Regression was conducted between ISMI
(dependent variable) and demographic and clinical variables
(independent variables) including diagnosis, age, sex, occupa-
tion, marital status, having or not having partner, rent, the age
of the onset of the disorder, number of hospitalizations, years
of education, degree of education, CGI-O, and CGI-S. The
threshold for statistical significance was set at 5%.
The ethic commitee of University Hospital in Olomouc
approved the study. The investigation was conducted by the lat-
est version of the Helsinki Declaration and standards of Good
Clinical Practice.31 The patients signed informed consent.
Results
Sample description
The main characteristics of the sample are presented in Table 1.
Diagnostic groups statistically significantly differ in most of
the clinical and demographical parameters (Table 1). The
“mean age” differs statistically significantly between diagnos-
tic groups (see Table 1). The Bonferroni’s multiple comparison
tests showed that age of the patient with BPD is statistically
significantly lower in comparison with ages of all other
diagnostic groups (BPD vs SCH mean difference (diff) =−7.52,
t=3.06, P,0.05; BPD vs MDD mean diff =−15.54, t=5.76,
P,0.001; BPD vs BAD mean diff =−9.80, t=3.54, P,0.01;
BPD vs AD mean diff =−9.60, t=3.66, P,0.01).
The diagnostic groups had statistically significant differ-
ences in “male/female ratio” (Table 1) between diagnostic
groups. Post hoc head-to-head analysis showed the statisti-
cally significant differences between BPD and SCH (Fisher’s
exact test: P,0.0001), BPD and MDD (Fisher’s exact test:
P,0.01), but not between BPD and BAD (Fisher’s exact test:
not significant [n.s.]), alternatively, BPD vs AD (Fisher’s
exact test: n.s.).
There were statistical differences in the “marital status”
between the diagnostic groups (Table 1). Post hoc head-to-head
comparisons showed the statistically significant differences
between BPD and MDD (chi-square test: P,0.005), BPD and
BAD (chi-square test: P,0.05), BPD and AD (chi-square test:
P,0.05), where more patients with BPD are single, but not
between BPD and SCH (chi-square test: n.s.).
There was a significant difference between diagnostic
groups in “partnership” (Table 1). The “length of the education”
and “levels of education” (Table 2) differ significantly as
well. The Bonferroni’s multiple comparison tests showed
that it is due to the differences in the degree of education
between BPD vs BAD (P,0.001), not due to comparison
with other diagnostic groups.
There were statistically significant differences between
the diagnostic group in the “onset of the diseases” (Table 1).
The beginning of the psychiatric problems was recognized
significantly at an earlier age in BPD patients in comparison
with all other diagnostic groups (BPD vs SCH, P,0.05;
BPD vs MDD, P,0.001; BPD vs BAD, P,0; and BPD vs
AD, P,0.001).
Groups statistically significantly differ from each other
in the “number of hospitalizations” in psychiatry (Table 1).
When comparing the measurements using Dunn’s multiple
comparison test, there was shown that the difference is due
to the dissimilarities between the BPD and MDD (P,0.01),
BPD and AD (P,0.001), and not with other diagnostic
groups (SCH, BAD).
Severity of the disorder
There was a statistically significant difference between diag-
nostic groups in “CGI-O” (Kruskal–Wallis statistic). The
comparison between the groups for the severity of the disor-
der by using the Dunn’s multiple comparison tests, showed
that the differences between the BPD and all other diagnostic
groups (Table 1). When comparing the scores in subjec-
tive “CGI-S”, there was statistically significant difference
between diagnostic groups also. According to the Dunn’s
multiple comparison tests, which compare each pair of the
groups, the differences were found between BPD and SCH,
and BPD and BAD, not between other groups (Table 1).
ISMI scores in different diagnostic groups
The “ISMI-TS” was 63.51±14.57. There was a high statisti-
cally significant difference among diagnostic groups accord-
ing to the “ISMI-TS” (Table 1). When using the correction for
multiple comparisons by Bonferroni’s multiple comparison
test, there were revealed differences between BPD patients
and patients with AD. No other statistical differences between
groups were detected in multiple comparisons.
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Self-stigma in borderline personality disorder
The groups differ in particular between the ISMI subscale
“alienation” (Table 1). The Bonferroni’s multiple comparison
tests demonstrated that it is due to the differences between
BPD and SCH (P,0.001), MDD (P,0.01), BAD (P,0.001),
and AD (P,0.001). The level of alienation is higher in BPD
group than in all others.
The groups did not differ between the subscale “stereo-
type endorsement”, but there was a significant difference in
Table 1 Demographic and clinical data of the patients
Categories All BPD SCH MDD BAD AD Statistics
(comparison diagnoses)
Number (%) 184 (100) 35 (19.0) 49 (26.6) 33 (17.9) 30 (16.3) 37 (20.1)
Age (year) (mean ± SD) 38.29±12.02 29.97±9.64 37.49±10.54 45.52±11.31 39.77±11.91 39.57±12.29 One-way ANOVA:
F=8.698, df=183; P,0.0001
Sex (n)
Males 83 7 32 18 12 14 Chi-square test; P,0.001
Females 101 28 17 15 18 23
Employment (n)
Yes 84 8 18 18 16 23 Chi-square test; P,0.01
No 100 27 31 15 14 14
Marital status (n)
Single 90 23 33 9 12 13 Chi-square test; P,0.005
Married 63 5 8 19 13 18
Divorced 27 6 7 5 3 6
Widowed 4 1 1 0 2 0
Living with partner (n)
Yes 85 16 12 21 18 28 Chi-square test; P,0.0001
No 95 39 37 12 12 9
Rent (n)
No rent 103 26 19 18 14 26 Chi-square test; P,0.0001
Partial disability rent 40 3 23 5 5 4
Full disability rent 30 6 7 6 7 4
Old-age pension 11 0 0 4 4 3
Education (n)
Basic 23 11 6 1 1 4 Chi-square test; P,0.0001
Lower educational training 41 4 9 14 2 12
Secondary 72 16 22 9 10 15
University 48 4 12 9 17 6
Years of education
(mean ± SD)
13.58±2.91 12.20±2.75 13.55±2.85 13.82±2.70 15.63±2.85 13.05±2.51 Kruskal–Wallis test: 21.18;
P,0.001
Onset of the disorder
(mean ± SD)
29.46±12.07 19.03±5.98 26.04±9.66 35.67±13.83 28.50±11.02 33.03±11.70 One-way ANOVA:
F=12.97, df=183; P,0.0001
Number of hospitalizations
(mean ± SD)
3.13±3.21 5.67±4.72 3.10±2.44 1.81±2.40 4.93±3.58 0.73±0.93 Kruskal–Wallis test: 58.64;
P,0.001
ISMI total score (mean ± SD) 63.51±14.57 71.15±14.74 63.20±13.27 64.09±12.20 62.00±14.21 57.62±15.85 One-way ANOVA:
F=4.225, df=183; P,0.005
Alienation (mean ± SD) 13.58±4.30 16.91±4.31 12.76±3.92 13.27±3.05 12.80±4.12 12.51±4.54 One-way ANOVA:
F=7.316, df=183; P,0.0001
Stereotype endorsement
(mean ± SD)
13.65±3.52 14.46±3.81 13.76±3.30 14.09±3.36 13.27±3.48 12.65±3.62 One-way ANOVA:
F=1.449, df=183; n.s.
Discrimination experience
(mean ± SD)
10.27±3.45 11.88±3.37 10.55±3.81 9.78±2.69 9.93±2.75 9.14±3.70 One-way ANOVA:
F=3.334, df=183; P,0.05
Social withdrawal (mean ± SD) 13.11±4.03 15.12±3.99 12.84±3.92 13.21±3.23 12.80±4.15 11.78±4.27 One-way ANOVA:
F=3.379, df=183; P,0.05
Stigma resistance (mean ± SD) 12.64±2.88 11.35±2.88 13.31±2.69 13.73±2.45 13.20±2.88 11.54±2.83 One-way ANOVA:
F=5.674, df=183; P,0.0005
CGI-O (mean ± SD) 3.16±1.60 4.57±1.50 3.04±1.47 3.27±1.44 2.50±1.33 2.41±1.32 Kruskal–Wallis test: 40.41;
P,0.0001
CGI-S (mean ± SD) 3.31±1.71 4.29±1.43 2.74±1.79 3.73±1.74 2.73±1.55 3.24±1.50 Kruskal–Wallis test: 24.38;
P,0.0001
Abbreviations: AD, anxiety disorder; ANOVA, analysis of variance; BAD, bipolar affective disorder; BPD, borderline personality disorder; CGI-O, clinical global impression –
objective; CGI-S, clinical global impression – subjective; df, degrees of freedom; ISMI, internalized stigma of mental illness scale; MDD, major depressive disorder;
SCH, schizophrenia spectrum disorder.
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subscale “discrimination experience” (Table 1). The differ-
ence reaches statistical significance in comparison of BPD
and AD (P,0.01) but not in comparisons with other diagnos-
tic groups (Bonferroni’s multiple comparison tests: n.s.).
The comparison of ISMI subscale “social withdrawal”
shows the statistically significant differences between
diagnostic groups in one-way analysis of variance statis-
tic (F=3.379, df=183; P,0.05). When the correction for
the multiple comparisons using the Bonferroni’s multiple
comparison test was applied, statistically significant differ-
ences occurred only between BPD and AD patients (P,0.01)
but not in the comparisons with other diagnostic groups.
The last subscale of the ISMI is “stigma resistance”.
There were large statistically significant differences between
diagnostic groups in stigma resistance (F=5.674, df=183;
P,0.0005). In Bonferroni’s multiple comparison tests were
shown, that BPD group was different from SCH (P,0.05),
MDD (P,0.01), but not from BAD and AD.
ISMI relationship with demographic
and clinical variables
ISMI-TS did not correlate with the age and sex, but it cor-
related significantly with the age of disease onset, the years
of education, and number of hospitalizations (Table 2).
There was strong statistical significant difference between
employed and unemployed patients, while higher stigma,
had patients with no job. There were no differences in mean
self-stigma level between groups divided according to marital
status, according to the presence of any retirement/pension
or not, and the degree of education (Table 2). However,
there was the strong statistically significant difference in
ISMI-TS between patients with a partner and patients without
a partner (Table 2).
There were statistically significant correlations among the
ISMI-TS and CGI-S or CGI-O evaluation of the severity of
the disorder and with an index of antidepressants (Table 2).
There was also statistically significant correlation with the
years of education (Spearman’s r=−0.1625, P,0.05).
There was a significant correlation between mean anti-
depressant dosage (according to the index of the antidepres-
sant), but not with an index of antipsychotic or anxiolytic
dosage (Table 2).
Multiple regression analysis of signicant
factors connected to the self-stigma
Due to the several factors significantly related to the self-
stigma, we decided to calculate a multiple regression
analysis to find essential elements. The dependent variable
was the ISMI-TS scale while CGI-O, CGI-S, the age of
onset, diagnosis, years of education, partnership, number of
hospitalizations, and employment were independent vari-
ables (see variables in Table 3). The method applied was a
stepwise regression analysis. The resultant model explained
28.9% of the dependent variable. The strongest factors con-
nected to self-stigma was being without partner, number of
hospitalizations, and the severity of the disorder measured
by CGI-O and CGI-S.
Table 2 Relationship between ISMI and demographic factors
Demographic factors Correlation or
comparison of the
ISMI total score
Statistics
Age (year) Pearson r=−0.05171 n.s.
Age of the disorder onset Spearman r=−0.1701 P,0.05
Number of hospitalizations Spearman r=0.2399 P,0.005
Years of education Spearman r=−0.1625 P,0.05
CGI-O Spearman r=0.4216 P,0.001
CGI-S Spearman r=0.4687 P,0.001
Antidepressant index Spearman r=0.2105 P,0.05
Antipsychotics index Spearman r=−0.1059 n.s.
Anxiolytics index Spearman r=0.0804 n.s.
Sex (mean ± SD)
Males 62.42±14.01 Unpaired t-test:
Females 64.35±15.02 t=0.8576, df=181; n.s.
Employment (mean ± SD)
Yes
No
58.69±13.79
67.52±14.04
Unpaired t-test: t=4.272,
df=181; P,0.0001
Marital status (mean ± SD)
Single 64.71±14.18 One-way ANOVA:
Married 61.02±15.07 F=1.461, df=182; n.s.
Divorced 63.93±14.67
Widowed 73.50±10.85
Partner (mean ± SD)
Yes 60.20±14.06 Unpaired t-test: t=3.281,
df=181; P,0.005
No 67.09±14.34
Benets (mean ± SD)
No rent 61.07±15.18 One-way ANOVA:
Partial disability rent 66.70±14.21 F=2.412, df=182; n.s.
Full disability rent 67.53±12.12
Old-age pension 63.64±13.10
Education (mean ± SD)
Basic school 68.59±16.34 One-way ANOVA:
Lower vocational
training
64.00±11.64 F=1.962, df=182; n.s.
High school 64.10±14.52
University 59.90±15.58
Abbreviations: ANOVA, analysis of variance; CGI-O, clinical global impression –
objective; CGI-S, clinical global impression – subjective; df, degrees of freedom;
ISMI, internalized stigma of mental illness scale; n.s, not signicant.
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Self-stigma in borderline personality disorder
Discussion
There were statistically significant differences between diag-
nostic groups in the studied sample in many demographic
features. With a focus on BPD, the patients with BPD were
statistically significantly younger than patients with other
diagnostic subgroups and their problems started earlier in
the life. This result is in agreement with the diagnosis of
personality disorder, the features and challenges of which are
typically clearly recognizable in the adolescents.11,25
There were 80% of the BPD females in our sample
which is in agreement with the previous finding according to
which ~75% of BPD patients are females.32 Only 14% of the
patients with BPD were married (comparable with schizo-
phrenic patients – 16%), which is very low in comparison
with the current average in the Czech Republic. Another
29.1% live with a partner; the percentage is comparable with
a study of Skodol et al33 with 27% BPD patients living with
a partner. Another explanation is the age – other diagnostic
groups were significantly older than BPD patients.
There were 70% of unemployed BDP patients in our
sample, which is more than ten times greater than the aver-
age unemployment rate in the Czech Republic.34 Borderline
patients are unemployed in higher percentage above all other
studied group of disorders. Unemployment rate corresponds
to 69% of those found in other larger study.33 The level of
unemployment in addition to personality disorder may also
be related to a high proportion of patients who have only
basic education (31%).
Patients with BPD have been youngest, but nevertheless,
they were hospitalized the most frequently from all diagnostic
groups, comparable only with the patients with BAD. In con-
trast, comparable with AD patients, most patients with BPD
have no rent, which can indirectly testify for underestimation
of the suffering and difficulties associated with BPD by Czech
committees for disabilities.
The ISMI-TS 63.51±14.57 of the whole sample is compara-
ble with the scores of other Czech studies with SCH,35,36 mixed
AD,16 MDD,37 BAD,38 or mixed diagnostic population.39 It is
a medium–high self-stigma score close to the mean score
for the patients’ population evaluated for the standardization
of the ISMI in mixed diagnosed Czech patients population.28
The mean scores of ISMI of our patients are also by the
self-stigma studies in other countries.40 In our study, the
level of self-stigma in patients with BPD was the highest of
all compared diagnostic groups. Patients with BPD showed
not only highest rate of overall self-stigma but also in all
subscales of ISMI except stigma resistance.
Some personality factors, which characterize BPD, can
be closely connected to self-stigma. Dominant sign of BPD
is disturbances and uncertainty about self-concept,11,25 and
patients with higher levels of self-stigma typically lose their
former self-concept.41 BPD patients score highly on harm
avoidance scales,42 and this personality trait can increase
the probability of development of self-stigma later in life.43
Self-directedness is reduced in BPD patients,44 and this
personality trait is also linked to self-stigma.43 Schema con-
cept postulates the existence of maladaptive schemas, self-
defeating emotional and cognitive patterns established from
childhood and repeated throughout life.45,46 Schemas in BPD
have a similar content as the self-stigmatization assertions
and beliefs, which are measured by the ISMI scale.
The objective CGI in BPD evaluated by outpatient psy-
chiatrist show the statistically significant higher severity of
the disorder in patients with BPD in comparison with the
each of another diagnostic group.
Patients with BPD had the highest value of CGI-O of all
researched disorders in our sample. The subjective CGI in
BPD demonstrate the same: is greater in BPD patient than in
other diagnostic groups. The results demonstrate the severity
of the impact of BPD in the patient.
One of the results is that higher self-stigma in this diag-
nostic group is connected with younger age. However, as
shown the correlation between ISMI and age, there was not
signification relationship between the self-stigma and age in
the whole sample. This finding is consistent with findings of
Holubova et al36 in an outpatient population of patients with
SCH, with the results of Ociskova et al16 in AD, and with
results of Cinculova et al37 in patients with the MDD.
The findings indicated that ISMI-TS did not relate to age,
sex, level of the education, supporting the results of the most
studies of self-stigma, and demographic factors.16,36,47–50 This
result does not correspond with the results of some other
studies. In a study of Girma et al51 there was the signifi-
cantly higher rate of ISMI-TS in females than in males and
self-stigma decreased with increasing levels of education.
Table 3 Multiple regression analysis with self-stigma as the depen -
dent variable
Regressor B SE βt P-value
CGI-S 2.960 0.671 0.345 4.411 ,0.001
Partnership −5.444 1.853 −0.187 −2.938 ,0.005
Number of hospitalizations 0.731 0.296 0.161 2.469 ,0.05
CGI-O 1.478 0.746 0.160 1.981 ,0.05
Note: Adjusted r2=0.289.
Abbreviations: B, unstandardized coefcients B; β, standardized coefcients beta;
CGI-O, clinical global impression – objective; CGI-S, clinical global impression –
subjective; SE, standard error.
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Grambal et al
On the other hand, Yen et al52 detected the relation among
sex, age, and self-stigma. Mosanya et al53 found an inverse
relationship between the level of education and degree of
self-stigma. Different results of our study may be associated
with the use of different scales to evaluate self-stigma, the
different socioeconomic and cultural environment, or with
the participation of other diagnostic groups of patients. By
our findings is the review and meta-analysis of 127 articles
dealing with stigma and self-stigma mainly in developed
countries, which found no significant relationship between
main demographic factors, such as age, sex, and education
and the self-stigma.1
Unemployment was connected with higher level of self-
stigma, what is similar as described by the study of Evans-
Lacko et al.40 It seems that getting a job can be an important
factor that could limit self-stigma. These findings highlight
the importance of employment programs to improve the lives
of people with mental disorders which also could reduce self-
stigma.54 Multiple regression analysis of significant factors
connected to the self-stigma showed a strong association
with, being without partner, the severity of the disorder, and
the number of previous hospitalizations.
Important factor linked to the self-stigma is a partnership,
that is, patients with BPD, who have no partner significantly
more self-stigmatized. It is impossible to determine the cau-
sality of this connection, but it can be assumed that patients
who are more self-stigmatized also have difficulties with
starting and maintaining the close relationship, the absence
of a relationship then contributes to self-stigma.
Self-stigma was significantly positively associated with the
CGI-S and CGI-O evaluations of a mental state, which may
reflect the link between stigma and subjectively and objec-
tively perceived differences between individuals from the
norm in the severity of the disorder.1 Our results are consistent
with Ocisková et al.28 The relationship between the number of
previous hospitalizations and self-stigma could be given with
a prerequisite for the patient and his close persons that patients
with higher number of hospitalizations must be more seriously
ill. Another possibility is that repeated hospitalization of BPD
patients increases contact with the stigmatizing personnel and
contribute to the internalization of stigma.55
Demographic data above shows how significant is dis-
abling in various areas of life in patients with BPD. Also, this
disability is relatively stable over time if symptoms of BPD
are present.56 This information suggests the importance of
finding an effective treatment for patients with BPD since the
reduction of BPD symptoms could be followed by improve-
ments in work and relationships. As we have described, job
and partnership are also linked with the degree of self-stigma.
Another possibility is to focus the therapy directly to the
self-stigma. Livingston and Boyd identified that stigma
interventions are successfully reduced self-stigma in people
with the various psychiatric disorder. One intervention
involved Internet modules for psychoeducation and cognitive
behavioral therapy (CBT), and the other group involved CBT
sessions.1 Group intervention to help persons with SMI can
reduce internalized stigma.57 Yanos et al22,23 and Roe et al24
developed narrative enhancement and cognitive therapy for
helping SMI patients to recognize and deal with self-stigma.
This approach may serve as an inspiration for the programs
for fighting with self-stigma in BPD. Authors cultivated an
intervention that would consist of not only psychoeducation
materials about internalized stigma but also methods aimed
at increasing the cognitive skills required for correcting dys-
functional cognitions which might impede the development
of a different sense of self and positive identity.
Limitations of the study
Limitations of the investigation include not using the
structured clinical interview such as the severe combined
immunodeficiency, small sample size, the cross-sectional
design; using a general objective evaluation scale, and the
single-site setting.
Conclusion
The self-stigma has a strong psychosocial and psychiatric
symptom connection, so it is recommended that clinicians dis-
cuss both societal stigma and self-stigma with patients and con-
sider using strategies such as CBT to challenge the accuracy
of patients’ perceptions of the stigma. Adequate interventions
that target to the self-stigma are essentially needed. Looking
in the context that self-stigma is connected with the severity
of the disorder, employment, and number of hospitalizations
the appropriate therapy could specifically focus on these fac-
tors. Another investigation should evaluate self-stigma over
the time of persons across the diagnostic disorder spectrum to
inform about specific stigma decreasing activities.
Acknowledgment
This paper was supported by the research grants IGA MZ
ČR NS 9752-3/2008.
Disclosure
The authors report no conflicts of interest in this work.
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