- Email: [email protected]
Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization
Journal of Clinical Neuroscience xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical study
Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization Sevda Korkmaz a,b,⇑, Aslı Kazgan a, Tuba Korucu a, Murat Gönen b, M. Zülfü Yilmaz b, Murad Atmaca a a b
Department of Psychiatry, Fırat University, Faculty of Medicine, Elazıg, Turkey Department of Neurology, Fırat University, Faculty of Medicine, Elazıg, Turkey
a r t i c l e
i n f o
Article history: Received 2 October 2018 Accepted 11 November 2018 Available online xxxx Keywords: Stigmatization Migraine Seeking psychological help
a b s t r a c t Objective: Although migraine patients experience more psychological problems when compared to the general population, they are usually not treated. The reasons for non-treatment of these problems are not clear. The anxiety and concern of migraine patients about stigmatization may also prevent them to express psychological symptoms. The present study aimed to investigate the attitudes and behavior of migraine patients about receiving psychological help and their concerns about stigmatization. Material and method: The study group included 50 18–49 years old patients diagnosed with migraine in the neurology clinic and the control group included 50 healthy individuals with similar age, gender socio demographic characteristics with the study group. Attitude Scale Towards Seeking Professional Help (ASPH-SF), Self-Stigma in Seeking Professional Help Scale (SSPHS), Intentions to Seek Psychological Help Scale (ISHP), Stigma Scale for Receiving Psychological Help (SSRPH) and Symptom Checklist (SCL90-R) were applied to all participants. Findings: The comparison of the patient and control groups based on SCL-90-R findings demonstrated that the patient group scores in somatization, anxiety (p = 0.000), depression (p = 0.003), anger (p = 0.02), interpersonal sensitivity (p = 0.006), phobia (p = 0.001), paranoid thoughts (p = 0.012), psychosis (p = 0.031) subscales and additional subscale (p = 0.014) and general symptom index (p = 0.001) scores were higher. Based on SCL 90, it was found that patients with higher levels of symptoms had higher social stigma scores when compared to patients with lower symptom levels (p = 0.007). Migraine patients with high symptom levels were found to have significantly lower rates of seeking psychiatric help (14% vs 33%) when compared to the control group. There was no difference between the patient and control groups based on ASPH-SF, SSPHS, ISPH and SSRPH scale scores. Conclusion: Although migraine patients exhibit higher levels of psychiatric symptoms when compared to healthy individuals, it was determined that only a minority of these patients receive psychiatric treatment. Especially patients with high level of psychiatric symptoms could have sought less psychiatric help due to the concerns of stigmatization. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction Migraine is a neurological disorder characterized by severe headaches that restrain daily activities of the individual and more prevalent in females when compared to males [1]. A wide range of psychiatric disorders, especially anxiety and depression, can accompany migraine [2]. Serotonergic dysfunction, central sensitization and adverse effects of the drugs used in the treatment of the disease may contribute to this comorbidity [3]. ⇑ Corresponding author at: Department of Psychiatry, Fırat University, Faculty of Medicine, Elazıg, Turkey. E-mail addresses: [email protected], [email protected] (S. Korkmaz).
Although psychological problems are more common among migraine patients when compared to the general population based on our clinical observations, these problems usually remain untreated. The reasons for the non-treatment of these problems are not clear. Migraine patients may not mention their psychological problems unless these are directly questioned, or they may not be aware of their psychiatric symptoms. It is also known that the tendency of migraine patients to suppress their emotions is higher than that of healthy individuals [4]. In migraine patient population, anxiety and concerns about stigmatization for seeking psychiatric help may also be factor in inexpression of psychological symptoms by the patients. Literature review demonstrated that there are no detailed studies on various forms of stigmatization due to attitudes and seeking direct psychological help among migraine patients.
https://doi.org/10.1016/j.jocn.2018.11.035 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
2
S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
The present study aimed to investigate the attitudes and behavior of patients diagnosed with migraine towards seeking psychiatric help and their perceptions on stigmatization. Also, the presence of psychiatric symptoms that may accompany migraine in these patients and relationship between these symptoms and stigmatization anxiety were studied in the present study. 2. Material and method The present case study was approved by the local ethics committee and conducted in compliance with the Helsinki declaration. Fifty 18–49 years old patients who were diagnosed with migraine based on International Headache Society (IHS) 2004 diagnostic criteria and admitted to the neurology clinic in our institution and participated in the study voluntarily participated subsequently in the present study. The patients were required to be diagnosed with migraine, however those with a physical or psychological condition that could prevent them to respond to the questionnaires and scales and those who were illiterate were excluded from the study. Furthermore, 50 healthy individuals with similar sociodemographic characteristics in terms of age and gender to the patient group and who participated voluntarily in the study were included in the control group. Attitude Scale Towards Seeking Professional Help, Self-Stigma in Seeking Professional Help Scale, Intentions to Seek Psychological Help Scale, Social Stigma Scale in Seeking Psychological Help and Symptom Checklist were applied to all participants. 2.1. Applied scales 2.1.1. Attitude Scale Towards Seeking Professional Help – Short form (ASPH-SF) This form of the Attitude Scale Towards Seeking Professional Help is the abbreviated form of the original scale that includes 29 items [5]. The short form includes 10 items. The items in the scale are in the form of a 4-point Likert-type scale that range between ‘I strongly disagree,’ and ‘I strongly agree’. The lowest score available in the scale is 10 and the highest score is 40. Higher scores reflect positive attitudes of the individual towards seeking psychological help, whereas lower scores indicate that the attitude towards receiving psychological help is negative.
2.1.4. Social Stigma Scale in Seeking Psychological Help (SSRPH) This is a 5-item scale developed by Komiya to assess the individual’s perception of social stigma due to seeking psychological help [8]. The scale items are answered using a 4-point Likerttype scale that ranges between (1) I strongly disagree and (4) I strongly agree. The lowest score available in the scale is 5 and the highest score is 20. A high score received by the individual in the scale reflects that the individual has a high perception that the society would stigmatize the fact that she or he seeks the help of a psychology professional, while a low score indicates that the individual has a low perception that the society would stigmatize the fact that she or he seeks the help of a psychology professional.
2.1.5. Symptom Checklist – 90 Item Revision (SCL-90-R) This is a scale used to trace the presence of ongoing psychological symptoms. It is a self-assessment scale that includes 90 items. Its sub-dimensions include somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thought and psychoticism and supplementary items [9]. There are 6–13 items in each dimension. Participants are expected to answer the questions based on the last 15 days. Each answer is scored between 0 and 4 points. The subscale scores are calculated by dividing the scores given by the subjects for the items to the number of items in that subscale. This is conducted for all subscales. The scores between 0 and 1.50 are considered typical, the scores between 1.51 and 2.50 are considered highsymptomatic and the scores between 2.50 and 4.00 are considered very high symptomatic.
3. Statistical analysis SPSS version 22 software was used for statistical analyses. The Student’s t test was used for the intergroup comparisons if the measured data exhibited normal distribution, and the MannWhitney-U test was used if not. ANOVA test was used to compare patients with high and low level of symptoms and the control group. p < 0.05 was considered as statistically significant.
4. Findings 2.1.2. Self-Stigma in Seeking Professional Help Scale (SSPHS) This is a 10-item scale developed by Vogel et al. to evaluate the self-stigmatization of an individual in seeking psychological assistance [6]. The items in the scale are in the form of a 5-point Likerttype scale that range between (1) strongly disagree to (5) strongly agree. The lowest score available in the scale is 10 and the highest score is 50. A high score obtained in the scale reflect high level of self-stigma when the individual receives psychological help from a specialist and a low score obtained in the scale reflect low level of self-stigma when the individual receives psychological help from a specialist. 2.1.3. Intentions to Seek Psychological Help Scale (ISPH) This is a data collection instruments with three sub-dimensions (relational problems, traumatic problems, affective and behavioral problems) that was developed to determine the intention of the individual to seek psychological help and includes 12 items [7]. The scale items are answered using a Likert-type 4-point scale that ranges between (1) I absolutely would not seek psychological help and (4) I absolutely would seek psychological help. The lowest score available in the scale is 12 and the highest score is 48. A high score received by an individual in the inventory indicates that the intention of this individual to seek psychological help is high.
The patient and control group socio-demographic characteristics such as age, gender, marital status, educational status, unemployment rate and smoking rate are presented in Table 1. It was determined that there was no significant difference between the patient and control groups based on ASPH-SF, SSPHS, ISPH and SSRPH scale scores (Table 2). The comparison of the patient and control groups based on SCL-90-R findings demonstrated that the patient group scores in somatization, anxiety (p = 0.000), depression (p = 0.003), anger (p = 0.02), interpersonal sensitivity (p = 0.006), phobia (p = 0.001), paranoid thoughts (p = 0.012), psychosis (p = 0.031) subscales and additional subscale (p = 0.014) and general symptom index (p = 0.001) scores were statistically significantly higher (Table 3). While the number of patients with high symptom levels was 14 in general, the number of patients who received psychiatric treatment was only 2 (14%). While the number of individuals with high symptom levels in the control group was 3 in general, the number of individuals who received psychiatric treatment was 1 in the same group (33%). Based on general SCL 90 scores, it was determined that the social-stigma scores of the patients with high symptom levels were significantly higher when compared to that of the patients with low symptom levels (p = 0.007) (Table 4).
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
3
S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 1 Comparison of patient and control group socio-demographics. Patient group
Gender (female) Marital status (married) Residence (central) Primary school High school College Employed Income level (low) Smoking Alcohol use Additional medical diseases Prior psychiatric treatment history Psychiatric disorder diagnosis in family
Control group
n
%
n
%
47 14 37 29 7 14 4 11 10 – 12 7 7
94 %28 %74 %58 %14 %28 %8 %22 %20 – %24 %14 %14
45 23 45 18 10 22 13 10 20 2 6 6 3
90 %46 %90 %36 %20 %44 %26 %20 %40 %4 %12 %12 %6
Table 2 Comparison of patient and control group scale scores.
Age ASPH-SF (attitude scale) SSPHS (self-stigma) ISPH (intent inventory) SSRPH (social stigma) SCL 90 somatic SCL 90 anxiety SCL 90 depression SCL 90 obsession SCL 90 personal sensitivity SCL 90 psychotic SCL 90 paranoid SCL 90 anger SCL 90 phobia SCL 90 supplementary SCL 90 general
Patient n:50 mean ± std.d
Control n:50 mean ± std.d
p
t
34.4 ± 9.05 27.5 ± 4.74 24.9 ± 4.7 30.7 ± 8.07 10.3 ± 3.25 1.6 ± 0.9 0.96 ± 0.8 1.24 ± 0.97 1.14 ± 0.95 1.22 ± 1.099 0.67 ± 0.86 0.98 ± 0.96 1.0 ± 0.98 0.64 ± 0.75 1.09 ± 0.9 1.1 ± 0.84
31.8 ± 10.6 27.6 ± 5.3 25.3 ± 5.52 32.3 ± 6.22 10.7 ± 3.32 0.6 ± 0.5 0.47 ± 0.45 0.75 ± 0.59 0.97 ± 0.64 0.72 ± 0.58 0.38 ± 0.37 0.57 ± 0.56 0.52 ± 0.53 0.24 ± 0.29 0.72 ± 0.51 0.6 ± 0.44
0.195 0.498 0.683 0.868 0.585 P < 0.001** p < 0.001** 0.003* 0.298 0.006* 0.031* 0.012* 0.002* p < 0.001** 0.014* p < 0.001**
1.306 0.680 0.410 0.167 0.548 6.863 3.715 3.085 1.046 2.837 2.186 2.572 3.110 3.490 2.510 3.579
ASPH-SF: Attitude Scale Towards Seeking Professional Help-Short Form. SSPHS: Self-Stigma in Seeking Professional Help Scale. ISPH: Intentions to Seek Psychological Help Scale. SSRPH: Social Stigma in Seeking Psychological Help Scale. * p < 0.05. ** p < 0.001.
Table 3 Number of patients with high and very high symptom levels in patient and control groups.
Somatic Anxiety Obsession Depression Interpersonal relations Psychosis Paranoid Anger Phobia Supplementary General
Number of patients with high and very high symptom levels based on subscales (n)
%
Number of patients with high and very high symptom levels based on subscales (n)
%
22 12 17 16 19 9 13 14 6 14 14
%44 %24 %34 %32 %38 %18 %26 %28 %12 %28 %28
3 2 8 5 3 – 2 1 – 4 3
%6 %4 %16 %10 %6 – %4 %2 – %8 %6
5. Discussion In our study, somatization, anxiety, depression, anger, interpersonal sensitivity, phobia, paranoid thought, psychotic and anger subscale scores of migraine patients were higher than those of the control group. However, it was determined that only 14% of patients with high psychiatric symptoms received psychiatric
treatment. Migraine is a disease with a prognosis characterized by attacks and leads to significant losses in the individual’s functions. Due to these features and applied medical treatments, the disease is often accompanied by psychiatric disorders. It was reported in the literature that 23.1% of migraine patients experienced psychological problems [10]. Depression and anxiety disorders are the most common comorbid psychiatric disorders
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
4
S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 4 Comparison of the scale scores of the patients with low and high symptom levels and the control group.
ASPH-SF (attitude scale) SSPHS (self-stigma) ISPH (intent inventory) SSRPH (social stigma) *
Number of patients with low symptom levels n:36 Mean ± std.d
Number of patients with high symptom levels n:14 Mean ± std.d
Control group
p
27.3 ± 4.99 24.1 ± 4.4 29.6 ± 8.75 9.42 ± 2.87
27.9 ± 4.2 26.9 ± 5.04 33.4 ± 5.33 12.6 ± 3.13
27.6 ± 5.3 25.3 ± 5.52 32.3 ± 6.21 10.7 ± 3.23
0.796 0.209 0.138 0.007*
p < 0.05.
[11,12]. The quality of life of migraine patients was also found to be significantly lower than that of healthy individuals due to the direct clinical symptoms of the disease and comorbid psychological problems [13,14]. Although migraine is accompanied by several psychiatric disorders,thesepsychiatricproblemsareoftennotdiagnosedandtherefore not treated. It was determined that the most important factor that affect the behavior of seeking psychiatric help in the society is the fear ofstigmatization[15].Stigmaisthenegativeassessmentofanindividual or a group as defective or disfavored based on characteristics such as psychological and biological illnesses, ethnic group membership, drugabuseorphysicaldisability[16].Asaresultofthestigma,patients and their relatives are isolated from society and do not exhibit healthcareseekingbehavior[17].Infact,previousstudiesdemonstratedthat the tendency of migraine patients to suppress their emotions was higher than healthy individuals [4]. In the present study, it was found thattheattitudesandperspectivesofmigrainepatientstowardsseeking psychological assistance and stigmatizing thoughts were not different when compared to those of the healthy control group. However, it was determined that patients with high level of psychiatric symptoms had higher social stigma scores when compared to patientswithlowlevelofsymptoms.Negativeperceptionsaboutindividuals with psychological disorders affect individuals in need of treatment,which could lead to suppression of psychological concerns andavoidanceoftreatmenttoreducethenegativeconsequencesassociatedwiththestigma[6,15].Onlyasmallpercentageoftheseindividuals may receive psychiatric support since they experience the fear of stigmatization in case they receive psychiatric help. The decision to receive psychological help can also affect alexithymia, which is defined as recognition and interpretation of the individual’s need for psychological help [18,19]. In fact, previous studies reported that migraine patients have more alexithymia when compared to the control [20,21]. However, since the present study did not use alexithymia and similar scales, it would be difficult for us to comment on this issue. The low number of patients in the study group, the fact that the study group included mostly female subjects, and the fact that the psychiatric symptoms were only reviewed using scales were significant limitations of the present study. Careful investigation of psychiatric symptoms in migraine patients would prevent neglection of the psychological symptoms that accompany the disease and disrupt the treatment. Determination of the mental illnesses that accompany the migraine would contribute to the treatment of the disease and prevent the disease to become chronical and increase the quality of life of the patients. In this group of patients, there is a need for further studies on the reasons for the high number of applications for the treatment of psychiatric symptoms.
References [1] Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. (2nd Ed.). Cephalalgia 2004;24:1–151. [2] Scher AI, Bigal ME, Lipton RB. Comorbidity of migraine. Curr Opin Neurol 2005;18:305–10. [3] Bıçakçı Sß. Comorbidity of migraine. Arch Neuropsychiatry 2013;50(Suppl 1):14–20. [4] Passchierl J, Goudswaard P, Orlebeke JF, Verhage F. Migraine and defense mechanisms: psychophysiological relationships in young females. Soc Sci Med 1988;26:343–50. [5] Fischer EH, Farina A. Attitudes toward seeking professional psychological help: a shortened form and considerations for research. J College Stud Dev 1995;36 (4):368–73. [6] Vogel DL, Wade NG, Hackler AH. Perceived public stigma and the willingness to seek counseling: the mediating roles of self-stigma and attitudes toward counseling. J Counsel Psychol 2007;54(1):40–50. [7] Topkaya N. Structural equation analysis of willingness to seek psychological help by the roles of social stigma, treatment fears, anticipated benefits, risks, _ and attitudes toward therapy Unpublished doctoral thesis. Izmir, Türkiye: Ege Üniversitesi, Sosyal Bilimler Enstitüsü; 2011. [8] Komiya N, Good GE, Sherrod NB. Emotional openness as a predictor of college students’ attitudes toward seeking psychological help. J Counsel Psychol 2000;47:138–43. [9] Derogatis LR. SCL-90-R. Administration, scoring, and procedures manual. Minneapolis: NCS; 1994. _ Balaban H, Yag˘ız AK, Kavakçı Ö. Prevalence of migraine and co[10] Sß entürk IA, morbid psychiatric disorders among students of Cumhuriyet University. J Headache Pain 2013;14(1):34). _ Kutluhan S, Yürekli VA, Demirci K, Akdag˘ C, Zengin E. Neurologic and [11] Aydın FI, psychiatric comorbidity in migraine patients. Turkiye Klinikleri J Med Sci 2013;33(1):59–66. [12] Louter MA, Pijpers JA, Wardenaar KJ, van Zwet EW, van Hemert AM, Zitman FG, et al. Symptom dimensions of affective disorders in migraine patients. J Psychosom Res 2015 Nov;79(5):458–63. [13] Senaratne R, Van Ameringen M, Mancini C, Patterson B, Bennett M. The prevalence of migraine headaches in an anxiety disorders clinic sample. CNS Neurosci Ther 2010;16:76–82. [14] Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ, Stewart WF. Migraine, quality of life, and depression: a population-based case control study. Neurology 2000;55:629–35. [15] Corrigan PW. How stigma interferes with mental health care. Am Psychol 2004;59:614–25. [16] King M, Dinos S, Shaw J, Watson R, et al. The stigma scale: development of a standardised measure of the stigma of mental illness. Br J Psychiatry 2007;190:248–54. [17] Çam O, Bilge A. The process of stigmatization, attitude, and belief about mental illness and patient in turkey: a systematic review. J Psychiatr Nurs 2013;4 (2):91–101. [18] Bilican FI. Help seeking attitudes and behaviors regarding mental health among Turkish college students. Int J Mental Health 2014;42:43–59. [19] Pill R, Prior L, Wood F. Lay attitudes to professional consultations for common mental disorder: a sociological perspective. Br Med Bull 2001;57:207–19. [20] Muftuoglu MN, Herken H, Demirci H, Neyal A. Alexithymic features in migraine patients. Eur Arch Psychiatry Clin Neurosci 2004;254:182–6. [21] Karsßıkaya S, Kavakcı Ö, Kug˘u N, Selcen A. Post-traumatic stress disorder in migraine patients: migraine, trauma and alexithymia. Arch Neuropsychiatry 2013;50:263–8.
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Clinical study
Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization Sevda Korkmaz a,b,⇑, Aslı Kazgan a, Tuba Korucu a, Murat Gönen b, M. Zülfü Yilmaz b, Murad Atmaca a a b
Department of Psychiatry, Fırat University, Faculty of Medicine, Elazıg, Turkey Department of Neurology, Fırat University, Faculty of Medicine, Elazıg, Turkey
a r t i c l e
i n f o
Article history: Received 2 October 2018 Accepted 11 November 2018 Available online xxxx Keywords: Stigmatization Migraine Seeking psychological help
a b s t r a c t Objective: Although migraine patients experience more psychological problems when compared to the general population, they are usually not treated. The reasons for non-treatment of these problems are not clear. The anxiety and concern of migraine patients about stigmatization may also prevent them to express psychological symptoms. The present study aimed to investigate the attitudes and behavior of migraine patients about receiving psychological help and their concerns about stigmatization. Material and method: The study group included 50 18–49 years old patients diagnosed with migraine in the neurology clinic and the control group included 50 healthy individuals with similar age, gender socio demographic characteristics with the study group. Attitude Scale Towards Seeking Professional Help (ASPH-SF), Self-Stigma in Seeking Professional Help Scale (SSPHS), Intentions to Seek Psychological Help Scale (ISHP), Stigma Scale for Receiving Psychological Help (SSRPH) and Symptom Checklist (SCL90-R) were applied to all participants. Findings: The comparison of the patient and control groups based on SCL-90-R findings demonstrated that the patient group scores in somatization, anxiety (p = 0.000), depression (p = 0.003), anger (p = 0.02), interpersonal sensitivity (p = 0.006), phobia (p = 0.001), paranoid thoughts (p = 0.012), psychosis (p = 0.031) subscales and additional subscale (p = 0.014) and general symptom index (p = 0.001) scores were higher. Based on SCL 90, it was found that patients with higher levels of symptoms had higher social stigma scores when compared to patients with lower symptom levels (p = 0.007). Migraine patients with high symptom levels were found to have significantly lower rates of seeking psychiatric help (14% vs 33%) when compared to the control group. There was no difference between the patient and control groups based on ASPH-SF, SSPHS, ISPH and SSRPH scale scores. Conclusion: Although migraine patients exhibit higher levels of psychiatric symptoms when compared to healthy individuals, it was determined that only a minority of these patients receive psychiatric treatment. Especially patients with high level of psychiatric symptoms could have sought less psychiatric help due to the concerns of stigmatization. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction Migraine is a neurological disorder characterized by severe headaches that restrain daily activities of the individual and more prevalent in females when compared to males [1]. A wide range of psychiatric disorders, especially anxiety and depression, can accompany migraine [2]. Serotonergic dysfunction, central sensitization and adverse effects of the drugs used in the treatment of the disease may contribute to this comorbidity [3]. ⇑ Corresponding author at: Department of Psychiatry, Fırat University, Faculty of Medicine, Elazıg, Turkey. E-mail addresses: [email protected], [email protected] (S. Korkmaz).
Although psychological problems are more common among migraine patients when compared to the general population based on our clinical observations, these problems usually remain untreated. The reasons for the non-treatment of these problems are not clear. Migraine patients may not mention their psychological problems unless these are directly questioned, or they may not be aware of their psychiatric symptoms. It is also known that the tendency of migraine patients to suppress their emotions is higher than that of healthy individuals [4]. In migraine patient population, anxiety and concerns about stigmatization for seeking psychiatric help may also be factor in inexpression of psychological symptoms by the patients. Literature review demonstrated that there are no detailed studies on various forms of stigmatization due to attitudes and seeking direct psychological help among migraine patients.
https://doi.org/10.1016/j.jocn.2018.11.035 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
2
S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
The present study aimed to investigate the attitudes and behavior of patients diagnosed with migraine towards seeking psychiatric help and their perceptions on stigmatization. Also, the presence of psychiatric symptoms that may accompany migraine in these patients and relationship between these symptoms and stigmatization anxiety were studied in the present study. 2. Material and method The present case study was approved by the local ethics committee and conducted in compliance with the Helsinki declaration. Fifty 18–49 years old patients who were diagnosed with migraine based on International Headache Society (IHS) 2004 diagnostic criteria and admitted to the neurology clinic in our institution and participated in the study voluntarily participated subsequently in the present study. The patients were required to be diagnosed with migraine, however those with a physical or psychological condition that could prevent them to respond to the questionnaires and scales and those who were illiterate were excluded from the study. Furthermore, 50 healthy individuals with similar sociodemographic characteristics in terms of age and gender to the patient group and who participated voluntarily in the study were included in the control group. Attitude Scale Towards Seeking Professional Help, Self-Stigma in Seeking Professional Help Scale, Intentions to Seek Psychological Help Scale, Social Stigma Scale in Seeking Psychological Help and Symptom Checklist were applied to all participants. 2.1. Applied scales 2.1.1. Attitude Scale Towards Seeking Professional Help – Short form (ASPH-SF) This form of the Attitude Scale Towards Seeking Professional Help is the abbreviated form of the original scale that includes 29 items [5]. The short form includes 10 items. The items in the scale are in the form of a 4-point Likert-type scale that range between ‘I strongly disagree,’ and ‘I strongly agree’. The lowest score available in the scale is 10 and the highest score is 40. Higher scores reflect positive attitudes of the individual towards seeking psychological help, whereas lower scores indicate that the attitude towards receiving psychological help is negative.
2.1.4. Social Stigma Scale in Seeking Psychological Help (SSRPH) This is a 5-item scale developed by Komiya to assess the individual’s perception of social stigma due to seeking psychological help [8]. The scale items are answered using a 4-point Likerttype scale that ranges between (1) I strongly disagree and (4) I strongly agree. The lowest score available in the scale is 5 and the highest score is 20. A high score received by the individual in the scale reflects that the individual has a high perception that the society would stigmatize the fact that she or he seeks the help of a psychology professional, while a low score indicates that the individual has a low perception that the society would stigmatize the fact that she or he seeks the help of a psychology professional.
2.1.5. Symptom Checklist – 90 Item Revision (SCL-90-R) This is a scale used to trace the presence of ongoing psychological symptoms. It is a self-assessment scale that includes 90 items. Its sub-dimensions include somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thought and psychoticism and supplementary items [9]. There are 6–13 items in each dimension. Participants are expected to answer the questions based on the last 15 days. Each answer is scored between 0 and 4 points. The subscale scores are calculated by dividing the scores given by the subjects for the items to the number of items in that subscale. This is conducted for all subscales. The scores between 0 and 1.50 are considered typical, the scores between 1.51 and 2.50 are considered highsymptomatic and the scores between 2.50 and 4.00 are considered very high symptomatic.
3. Statistical analysis SPSS version 22 software was used for statistical analyses. The Student’s t test was used for the intergroup comparisons if the measured data exhibited normal distribution, and the MannWhitney-U test was used if not. ANOVA test was used to compare patients with high and low level of symptoms and the control group. p < 0.05 was considered as statistically significant.
4. Findings 2.1.2. Self-Stigma in Seeking Professional Help Scale (SSPHS) This is a 10-item scale developed by Vogel et al. to evaluate the self-stigmatization of an individual in seeking psychological assistance [6]. The items in the scale are in the form of a 5-point Likerttype scale that range between (1) strongly disagree to (5) strongly agree. The lowest score available in the scale is 10 and the highest score is 50. A high score obtained in the scale reflect high level of self-stigma when the individual receives psychological help from a specialist and a low score obtained in the scale reflect low level of self-stigma when the individual receives psychological help from a specialist. 2.1.3. Intentions to Seek Psychological Help Scale (ISPH) This is a data collection instruments with three sub-dimensions (relational problems, traumatic problems, affective and behavioral problems) that was developed to determine the intention of the individual to seek psychological help and includes 12 items [7]. The scale items are answered using a Likert-type 4-point scale that ranges between (1) I absolutely would not seek psychological help and (4) I absolutely would seek psychological help. The lowest score available in the scale is 12 and the highest score is 48. A high score received by an individual in the inventory indicates that the intention of this individual to seek psychological help is high.
The patient and control group socio-demographic characteristics such as age, gender, marital status, educational status, unemployment rate and smoking rate are presented in Table 1. It was determined that there was no significant difference between the patient and control groups based on ASPH-SF, SSPHS, ISPH and SSRPH scale scores (Table 2). The comparison of the patient and control groups based on SCL-90-R findings demonstrated that the patient group scores in somatization, anxiety (p = 0.000), depression (p = 0.003), anger (p = 0.02), interpersonal sensitivity (p = 0.006), phobia (p = 0.001), paranoid thoughts (p = 0.012), psychosis (p = 0.031) subscales and additional subscale (p = 0.014) and general symptom index (p = 0.001) scores were statistically significantly higher (Table 3). While the number of patients with high symptom levels was 14 in general, the number of patients who received psychiatric treatment was only 2 (14%). While the number of individuals with high symptom levels in the control group was 3 in general, the number of individuals who received psychiatric treatment was 1 in the same group (33%). Based on general SCL 90 scores, it was determined that the social-stigma scores of the patients with high symptom levels were significantly higher when compared to that of the patients with low symptom levels (p = 0.007) (Table 4).
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
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S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx Table 1 Comparison of patient and control group socio-demographics. Patient group
Gender (female) Marital status (married) Residence (central) Primary school High school College Employed Income level (low) Smoking Alcohol use Additional medical diseases Prior psychiatric treatment history Psychiatric disorder diagnosis in family
Control group
n
%
n
%
47 14 37 29 7 14 4 11 10 – 12 7 7
94 %28 %74 %58 %14 %28 %8 %22 %20 – %24 %14 %14
45 23 45 18 10 22 13 10 20 2 6 6 3
90 %46 %90 %36 %20 %44 %26 %20 %40 %4 %12 %12 %6
Table 2 Comparison of patient and control group scale scores.
Age ASPH-SF (attitude scale) SSPHS (self-stigma) ISPH (intent inventory) SSRPH (social stigma) SCL 90 somatic SCL 90 anxiety SCL 90 depression SCL 90 obsession SCL 90 personal sensitivity SCL 90 psychotic SCL 90 paranoid SCL 90 anger SCL 90 phobia SCL 90 supplementary SCL 90 general
Patient n:50 mean ± std.d
Control n:50 mean ± std.d
p
t
34.4 ± 9.05 27.5 ± 4.74 24.9 ± 4.7 30.7 ± 8.07 10.3 ± 3.25 1.6 ± 0.9 0.96 ± 0.8 1.24 ± 0.97 1.14 ± 0.95 1.22 ± 1.099 0.67 ± 0.86 0.98 ± 0.96 1.0 ± 0.98 0.64 ± 0.75 1.09 ± 0.9 1.1 ± 0.84
31.8 ± 10.6 27.6 ± 5.3 25.3 ± 5.52 32.3 ± 6.22 10.7 ± 3.32 0.6 ± 0.5 0.47 ± 0.45 0.75 ± 0.59 0.97 ± 0.64 0.72 ± 0.58 0.38 ± 0.37 0.57 ± 0.56 0.52 ± 0.53 0.24 ± 0.29 0.72 ± 0.51 0.6 ± 0.44
0.195 0.498 0.683 0.868 0.585 P < 0.001** p < 0.001** 0.003* 0.298 0.006* 0.031* 0.012* 0.002* p < 0.001** 0.014* p < 0.001**
1.306 0.680 0.410 0.167 0.548 6.863 3.715 3.085 1.046 2.837 2.186 2.572 3.110 3.490 2.510 3.579
ASPH-SF: Attitude Scale Towards Seeking Professional Help-Short Form. SSPHS: Self-Stigma in Seeking Professional Help Scale. ISPH: Intentions to Seek Psychological Help Scale. SSRPH: Social Stigma in Seeking Psychological Help Scale. * p < 0.05. ** p < 0.001.
Table 3 Number of patients with high and very high symptom levels in patient and control groups.
Somatic Anxiety Obsession Depression Interpersonal relations Psychosis Paranoid Anger Phobia Supplementary General
Number of patients with high and very high symptom levels based on subscales (n)
%
Number of patients with high and very high symptom levels based on subscales (n)
%
22 12 17 16 19 9 13 14 6 14 14
%44 %24 %34 %32 %38 %18 %26 %28 %12 %28 %28
3 2 8 5 3 – 2 1 – 4 3
%6 %4 %16 %10 %6 – %4 %2 – %8 %6
5. Discussion In our study, somatization, anxiety, depression, anger, interpersonal sensitivity, phobia, paranoid thought, psychotic and anger subscale scores of migraine patients were higher than those of the control group. However, it was determined that only 14% of patients with high psychiatric symptoms received psychiatric
treatment. Migraine is a disease with a prognosis characterized by attacks and leads to significant losses in the individual’s functions. Due to these features and applied medical treatments, the disease is often accompanied by psychiatric disorders. It was reported in the literature that 23.1% of migraine patients experienced psychological problems [10]. Depression and anxiety disorders are the most common comorbid psychiatric disorders
Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035
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S. Korkmaz et al. / Journal of Clinical Neuroscience xxx (xxxx) xxx
Table 4 Comparison of the scale scores of the patients with low and high symptom levels and the control group.
ASPH-SF (attitude scale) SSPHS (self-stigma) ISPH (intent inventory) SSRPH (social stigma) *
Number of patients with low symptom levels n:36 Mean ± std.d
Number of patients with high symptom levels n:14 Mean ± std.d
Control group
p
27.3 ± 4.99 24.1 ± 4.4 29.6 ± 8.75 9.42 ± 2.87
27.9 ± 4.2 26.9 ± 5.04 33.4 ± 5.33 12.6 ± 3.13
27.6 ± 5.3 25.3 ± 5.52 32.3 ± 6.21 10.7 ± 3.23
0.796 0.209 0.138 0.007*
p < 0.05.
[11,12]. The quality of life of migraine patients was also found to be significantly lower than that of healthy individuals due to the direct clinical symptoms of the disease and comorbid psychological problems [13,14]. Although migraine is accompanied by several psychiatric disorders,thesepsychiatricproblemsareoftennotdiagnosedandtherefore not treated. It was determined that the most important factor that affect the behavior of seeking psychiatric help in the society is the fear ofstigmatization[15].Stigmaisthenegativeassessmentofanindividual or a group as defective or disfavored based on characteristics such as psychological and biological illnesses, ethnic group membership, drugabuseorphysicaldisability[16].Asaresultofthestigma,patients and their relatives are isolated from society and do not exhibit healthcareseekingbehavior[17].Infact,previousstudiesdemonstratedthat the tendency of migraine patients to suppress their emotions was higher than healthy individuals [4]. In the present study, it was found thattheattitudesandperspectivesofmigrainepatientstowardsseeking psychological assistance and stigmatizing thoughts were not different when compared to those of the healthy control group. However, it was determined that patients with high level of psychiatric symptoms had higher social stigma scores when compared to patientswithlowlevelofsymptoms.Negativeperceptionsaboutindividuals with psychological disorders affect individuals in need of treatment,which could lead to suppression of psychological concerns andavoidanceoftreatmenttoreducethenegativeconsequencesassociatedwiththestigma[6,15].Onlyasmallpercentageoftheseindividuals may receive psychiatric support since they experience the fear of stigmatization in case they receive psychiatric help. The decision to receive psychological help can also affect alexithymia, which is defined as recognition and interpretation of the individual’s need for psychological help [18,19]. In fact, previous studies reported that migraine patients have more alexithymia when compared to the control [20,21]. However, since the present study did not use alexithymia and similar scales, it would be difficult for us to comment on this issue. The low number of patients in the study group, the fact that the study group included mostly female subjects, and the fact that the psychiatric symptoms were only reviewed using scales were significant limitations of the present study. Careful investigation of psychiatric symptoms in migraine patients would prevent neglection of the psychological symptoms that accompany the disease and disrupt the treatment. Determination of the mental illnesses that accompany the migraine would contribute to the treatment of the disease and prevent the disease to become chronical and increase the quality of life of the patients. In this group of patients, there is a need for further studies on the reasons for the high number of applications for the treatment of psychiatric symptoms.
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Please cite this article as: S. Korkmaz, A. Kazgan, T. Korucu et al., Psychiatric symptoms in migraine patients and their attitudes towards psychological support on stigmatization, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.035