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Public stigma towards individuals with somatic symptom disorders – Survey results from Germany
Journal of Psychosomatic Research 115 (2018) 71–75
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Public stigma towards individuals with somatic symptom disorders – Survey results from Germany
T
Olaf von dem Knesebecka, , Marco Lehmannb, Bernd Löweb, Anna C. Makowskia ⁎
a b
Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg 20146, Germany Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, Martinistr 52, Hamburg 20146, Germany
ARTICLE INFO
ABSTRACT
Keywords: Somatic symptom disorder Public stigma Social distance Depression
Objective: The study aims to investigate (1) the magnitude of public stigma towards individuals with somatic symptom disorder (SSD), (2) differences in public stigma between SSD and depression, and (3) predictors of social distance towards individuals with SSD. Methods: Analyses are based on a national telephone survey in Germany (N = 1004). Two vignettes with symptoms of SSD were used. Vignettes differed regarding main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Stigma was measured by stereotypes, negative emotional reactions, and desire for social distance. Results: There were no significant differences in public stigma regarding type of symptom and existence of an earlier somatic disease. Two of three components of public stigma under study (stereotypes and desire for social distance) showed higher values in case of depression compared to SSD (both vignettes pooled). Age and negative emotional reactions were positively associated with desire for social distance in case of both SSD vignettes, whereas associations with stereotypes and experience (own affliction and contact to persons afflicted) were inconsistent. Education was not associated with social distance towards people with SSD. Conclusions: Results indicated public stigma towards people affected by SSD in Germany. Compared with depression, SSD stigma was lower in most components. Magnitude of SSD stigma was similar, irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Reducing SSD stigma could help to improve illness behaviour and prevent chronification.
1. Introduction A somatic symptom disorder (SSD) is defined on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms [1]. In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2], the somatoform disorder has been replaced by the category of SSD. In the course of this change, the medically unexplained criterion of the somatization disorder was omitted, whereas positive psychobehavioral criteria, namely high health anxiety, excessive symptom preoccupation, excessive health worry, and maladaptive illness behavior were included [3]. Stigma is one important aspect in the debate about the rationale and consequences of this categorical change [1,4,5]. However, studies analyzing stigma related to SSD are rare. Stigma can be defined as a process in which labeling, stereotyping, status loss and discrimination co-occur in a situation where power is exercised [6]. Public stigma is usually assessed by different beliefs
⁎
endorsed by the general population, such as the ascription of attributes (stereotypes), emotional response upon meeting an afflicted person (e.g. anger or fear) or the desire to socially distance oneself [7,8]. A recent review revealed that almost half of all public attitude research in Western countries focuses on depression [9]. In terms of predictors of public mental illness stigma, many studies focused on sociodemographic characteristics like gender, age and education yielding inconsistent results (for review please see [10]). Experiences with mental illness, i.e. being or having been afflicted by the mental illness or having personal contact with people suffering from mental illness, has been found to be negatively associated with stigma [10]. Public stigma imposes a great burden on those affected with negative consequences for their health and help-seeking behavior. Stigma can also be a barrier, which may impede diagnosis of somatoform and related disorders [11]. There are few studies analyzing stigma related to SSD or somatoform disorders but these primarily focus on perceived or anticipated
Corresponding author. E-mail address: [email protected] (O. von dem Knesebeck).
https://doi.org/10.1016/j.jpsychores.2018.10.014 Received 24 May 2018; Received in revised form 12 September 2018; Accepted 24 October 2018 0022-3999/ © 2018 Published by Elsevier Inc.
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stigma, and not on public stigma. In these studies, patients are asked whether they believe that they are stigmatized because of their disorder. Results indicate that the large majority of patients reports perceived stigma [12–14]. For example, in an Austrian study, about 3/4 of patients with a somatoform disorder worry that they are stigmatized because of their disorder [13]. A Canadian study found that there are greater levels of perceived stigma among patients with functional somatic symptoms compared to those with medical diagnoses [15]. However, it is unclear, to what extent the general public actually holds stigmatizing beliefs towards people affected by SSD and there is nothing known about possible predictors of public SSD stigma. In fact, the characteristics of functional somatic symptoms primarily focus on the inexplicability of the symptoms in medical terms. In contrast, the characteristics of SSD primarily focus on psychological concerns, anxiety, and symptom related behavior. Despite the fact that the patient groups with SSD and FSS substantially overlap [16], we cannot expect the same level of stigma if patient characterization is grossly different between the two classifications. Against this background, and based on a national population survey in Germany, the analyses will focus on the following research questions: What is the magnitude of public stigma (i.e. stereotypes, negative emotional reactions, and desire for social distance) towards individuals with SSDs? Are there differences in public stigma between SSD and depression? Are sociodemographic and experience-related factors predictors of social distance towards individuals with SSDs?
Table 1 Sociodemographic characteristics of the sample compared to official German statistics of the general population.
Sex (female, %) Level of education (%) ≤ 9 years 10 years ≥ 12 years Age (groups, %) 18–24 25–39 40–59 60–64 > 65
Vignette A (n = 499)
Vignette B (n = 505)
Sample (N = 1004)
Official statistics
p⁎
52.9
50.9
51.9
50.7a
0.73
35.7 30.2 34.2
33.6 32.0 34.4
34.7 31.1 34.2
34.2b 32.0b 33.5b
0.44
10.4 19.9 32.7 9.6 27.3
8.3 22.8 34.9 9.7 24.4
9.4 21.4 33.8 9.7 25.7
9.2c 22.5c 35.6c 7.6c 25.1c
0.19
a Federal Office of Statistics: Statistical Yearbook 2017, p 26 (Available online: https://www.destatis.de/DE/Publikationen/StatistischesJahrbuch/ StatistischesJahrbuch.html. Last accessed April 23, 2018). b Federal Office of Statistics: Statistical Yearbook 2017, p 84. c Federal Office of Statistics: Statistical Yearbook 2017, p 31 ⁎ χ2-test: sample against official German statistics.
symptom and existence of an earlier somatic disease. Vignettes were additionally varied according to gender (female vs. male) and age (32 years vs. 62 years), resulting in eight different vignettes that each were randomly assigned to about 125 respondents (i.e. about 12.5% of the sample). A trained speaker audio-recorded the vignettes. To neutralize possible interviewer effects, the files were directly played to the respondents from the computer via telephone line. For a comparison with public stigma towards individuals with a depression, we additionally use a preceding national telephone survey (N = 505) conducted in 2016 (for details please see [18]). In this survey, we also used a vignette, in this case with typical signs and symptoms suggestive of a depression.
2. Methods 2.1. Study design and sample Data from a national telephone survey via CATI (Computer-Assisted Telephone Interview) conducted in November and December 2017 in Germany were used for the analyses. Sample consisted of adults aged 18 and older, living in private households. About 70% of the sample was drawn from all registered private telephone numbers at random, additional computer-generated numbers also allowed for inclusion of exdirectory households (landline numbers). The other 30% of the sample consisted of randomly generated mobile phone numbers (Random Digit Dialing, RDD). For a random selection of participants in the households, the Kish-Selection Grid was applied [17]. Among mobile users, target person was the owner or main user of the mobile device. After having been informed that participation in the study is voluntary and that withdrawal from the study is possible at any time, 1004 individuals participated, reflecting a response rate of about 48.3%. Data collection procedure was approved by the Ethics Commission of the Medical Association in Hamburg (No. PV3707). Comparison of sociodemographic characteristics in the sample with official statistics indicates that distribution of age, gender, and education is similar to the general adult population in Germany (Table 1).
2.3. Instruments Three elements of the stigma process were assessed [6]: (1) characteristics ascribed to the person with SSD in the vignette (stereotypes), (2) negative emotional reactions, and (3) desire for social distance. Stereotypes were assessed using four items derived from a list of Angermeyer and Matschinger [19]. On a four-point Likert scale, respondents were asked to indicate to what extent they agree or disagree with the following statements: “The person described in the vignette is…” “…in need of help”, “…unpredictable”, “…scary”, “…sensitive”. Negative emotional reactions towards the person in the vignette were assessed by three items (angry, annoyed, and incomprehension). The items were taken from an instrument developed by Angermeyer and Matschinger [19]. Respondents were asked to agree or disagree to the respective emotional reaction on a four point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). We computed a sum score for emotional reactions ranging from 3 to 12; Cronbach's Alpha of the scale is 0.73. Desire for social distance was measured by a scale developed by Link et al. [20]. It is a modified version of the Bogardus Desire for Social Distance scale [21]. It includes seven items addressing various social relationships: tenant, co-worker, neighbor, child carer, in-law, and person one would recommend for a job or person of the same social circle. Respondents were asked to specify whether they would accept the described person in the vignette for each social relationship on a four-point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). A sum score (range from 7 to 28) was computed to assess the respondents' overall desire for social distance. Cronbach's Alpha of the Desire for Social Distance scale is 0.83.
2.2. Vignettes At the beginning of the interview, a vignette with signs and symptoms suggestive of a SSD was presented to the respondents in the survey. Two different vignettes were developed with the input of clinicians (see Appendix). Both vignettes show cases of a SSD according to DSM-5 [2]. The first sentence of both vignettes consists of information to fulfill both, the A criterion (burdensome somatic symptom) and the C criterion (persistence of symptom burden) of SSD. The subsequent sentences give information regarding the B criterion concerning excessive thoughts about the severity of the symptoms, severe anxiety about ones health and the symptoms, and excessive symptom related behavior. Vignette A shows a case of a SSD with pain as the main symptom without a comorbid somatic disease. In contrast, vignette B shows a case with fatigue as the main symptom and an earlier severe somatic disease. Thus, the two vignettes differ in terms of main type of 72
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In terms of predictors of social distance, previous studies indicate that sociodemographic and experience-related factors play an important role [10]. Age, gender, and education (highest educational degree) are introduced as sociodemographic characteristics. To asses respondents experience with symptoms described in the vignette, they were asked whether they themselves ever were afflicted by similar symptoms (yes vs. no). Moreover, they were asked whether they have or had personal contact to a person afflicted (yes vs. no). About 22% of the respondents reported that they are or were afflicted by similar symptoms described in vignette A (pain without somatic disease). Respective prevalence in case of vignette B (fatigue with earlier somatic disease) is 26%. Almost half of the respondents (47%) had personal contact to an individual with symptoms like the person in vignette A. This rate is higher in case of vignette B (62%).
Table 2 Stigmatizing attitudes towards a person with somatic symptom disorder depending on clinical picture presented in the vignette (means, standard deviations, and significances).
Stereotypesa The person in the vignette is… …in need of help …unpredictable …scary …sensitive Emotional reactionsa Upon meeting this person… …I react angrily. …I feel annoyed. …I react with incomprehension. Scale emotional reactionsb Desire for social distance with regard to the following relationshipsc Tenant Colleague Neighbor Childcare In-law Introduce friend Recommend for a job Desire for social distance scaled
2.4. Analyses To analyze the magnitude of public stigma (stereotypes, negative emotional reactions, and desire for social distance), means of the items and scales are compared and Mann-Whitney tests are calculated. To examine predictors of social distance, multiple linear regression analyses are conducted. Sociodemographic characteristics of the respondents (age, gender, and education), experience-related factors (affliction, contact to persons afflicted) as well as stereotypes and emotional reactions are introduced as predictors. Regression coefficients, 95%-confidence intervals, significances, and explained variances (R2) are documented in the tables.
Vignette A (pain without somatic disease, n = 499)
Vignette B (fatigue with previous somatic disease, n = 505)
p⁎
3.19 1.98 1.63 3.27
(0.72) (0.84) (0.73) (0.68)
3.13 1.99 1.58 3.27
(0.72) (0.81) (0.74) (0.68)
0.12 0.85 0.09 0.67
1.49 1.91 1.68 5.09
(0.70) (0.89) (0.81) (1.91)
1.52 1.86 1.68 5.07
(0.73) (0.83) (0.79) (1.92)
0.55 0.52 0.92 0.89
2.22 (0.98) 1.58 (0.69) 1.51 (0.65) 2.58 (0.97) 1.92 (0.88) 2.00 (0.83) 2.33 (0.93) 14.47 (3.24)
2.27 (0.97) 1.58 (0.71) 1.60 (0.76) 2.58 (0.96) 2.00 (0.92) 2.12 (0.96) 2.35 (0.92) 14.80 (3.39)
0.32 0.89 0.34 0.71 0.34 0.07 0.47 0.26
Mann-Whitney-U test. stereotypes and emotional reaction single items ranging from 1 ‘totally disagree’ to 4 ‘totally agree’. b emotional reaction scale ranging from 3 to 12, comprised of 3 items (sum score). c desire for social distance single items ranging from 1 ‘totally agree’ to 4 ‘totally disagree’. d desire for social distance scale comprised of 7 items, total score ranging from 7 to 28 (sum score). ⁎
a
3. Results Table 2 shows the stigmatizing attitudes (stereotypes, emotional reactions, and desire for social distance) towards the two cases of SSD. There are no significant differences between the two vignettes, i.e. magnitude of public stigma is similar irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). As there are no differences in stigma between the two SSD vignettes, these are pooled for the comparison with a depression vignette (Table 3). Stereotypes ascribed to the person in the vignette differ between SSD and depression. In case of an individual with depressive symptoms, respondents more often agreed that such a person is in need of help, is unpredictable, scary, and sensitive. In terms of negative emotional reactions, there are no significant differences between the SSD vignettes and depression, whereas desire for social distance is significantly more pronounced when the respondents are confronted with someone with a depression. Table 4 shows the associations of desire for social distance with sociodemographic characteristics of the respondents (age, gender, and education), experience-related factors (affliction, contact to persons afflicted) as well as stereotypes and emotional reactions for the SSD vignette A (pain without somatic disease). Higher age is associated with increased desire for social distance. Moreover, there is a stronger desire for social distance among those respondents who show negative emotional reactions or who agree that the person in vignette A is in need of help, unpredictable, or scary. The stereotype ‘sensitivity’ is associated with a decrease of social distance. In terms of vignette B (fatigue with previous somatic disease), desire for social distance towards persons with SSD is more pronounced among older respondents and among those who show negative emotional reactions and who agree that a person with SSD is scary (Table 5). Contrary, social distance significantly decreases when respondents report that they were afflicted by similar symptoms themselves.
4. Discussion To the best of our knowledge, this is the first study analyzing public stigma towards people affected by SSD. Using two different vignettes in a German general population survey, our results show that the magnitude of public stigma is similar in terms of stereotypes, emotional reactions and desire for social distance, irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Two of three components of public stigma under study (i.e. stereotypes and desire for social distance) show higher values in case of a person affected by depression compared to SSD (both vignettes pooled). Age and negative emotional reactions are positively associated with desire for social distance in case of both SSD vignettes, whereas associations with stereotypes and experience (own affliction and contact to persons afflicted) are inconsistent. Education is not associated with social distance towards people with SSD. As stereotypes, negative emotional reactions and desire for social distance were also assessed in a number of other German studies, our results can be compared with previous findings. Angermeyer et al. [22] compared the magnitude of public stigma across different mental disorders. Their results indicate that people with depression are confronted with lower levels of stigma than those with schizophrenia or alcohol dependence. Thus, compared with other mental illnesses, SSD stigma presented here is rather low. Compared to a German study [23], analyzing stigma in case of eating disorders (bulimia nervosa and anorexia nervosa), SSD stigma, however, is more pronounced. It can be assumed that people having persistent somatic symptoms and a medical diagnosis are less stigmatized than people having somatic symptoms 73
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Table 3 Stigmatizing attitudes towards persons with somatic symptom disorders and depression (means, standard deviations, and significances). Somatic Symptom Disorders (n = 1004)⁎
Depression (n = 505)
Table 5 Linear regression: associations with desire for social distance from someone with a somatic symptom disorder (Vignette B, fatigue with previous somatic disease).
p⁎⁎
Stereotypesab The person in the vignette is… …in need of help 3.16 (0.72) 3.34 (0.72) …unpredictable 1.99 (0.82) 2.48 (0.88) …scary 1.61 (0.74) 1.96 (0.84) …sensitive 3.27 (0.68) 3.36 (0.70) Emotional reactions a Upon meeting this person… …I react angrily. 1.51 (0.71) 1.48 (0.62) …I feel annoyed. 1.88 (0.86) 1.91 (0.86) …I react with 1.68 (0.80) 1.72 (0.83) incomprehension. Scale emotional reactions b 5.08 (1.91) 5.10 (1.82) Desire for Social Distance with regard to the following relationshipsc Tenant 2.24 (0.97) 2.43 (0.98) Colleague 1.58 (0.70) 1.62 (0.71) Neighbor 1.56 (0.71) 1.66 (0.73) Childcare 2.58 (0.96) 3.03 (0.88) In-law 1.96 (0.90) 2.32 (0.96) Introduce a friend 2.06 (0.93) 2.29 (0.91) Job recommendation 2.34 (0.93) 2.56 (0.88) Desire for Social Distance 14.33 (4.31) 15.77 (4.04) Scaled
Gender (ref. male) Age Level of education Experience with disorder Own affliction: yes (ref. no) Contact to someone with SSD (ref. no) Stereotypes In need of help Unpredictable Scary Sensitive Negative emotional reaction scale R2
< 0.001 < 0.001 < 0.001 0.003 0.53 0.91 0.81 0.88 0.001 0.15 0.004 < 0.001 < 0.001 0.009 < 0.001 < 0.001
0.222 0.031 0.359
0.027 0.143 0.072
−0.529 - 0.973 0.010–0.051⁎⁎ −0.108 - 0.827
−0.315 0.340
−0.032 0.041
−1.235 - 0.604 −0.419 - 1.099
0.735 0.700 1.039 −0.626 0.282 0.175
0.131 0.143 0.184 −0.103 0.128
0.226–1.243⁎⁎ 0.233–1.166⁎⁎ 0.480–1.598⁎⁎⁎ −1.190 - -0.061⁎ 0.064–0.500⁎
0.039 0.239 −0.002
−0.409 - 1.093 0.037–0.080⁎⁎⁎ −0.480 - 0.460
−0.891 0.543
−0.089 0.061
−1.744 - -0.038⁎ −0.225 - 1.311
−0.141 0.309 1.466 0.115 0.374 0.226
−0.024 0.057 0.244 0.019 0.167
−0.669 - 0.387 −0.204 - 0.822 0.874–2.036⁎⁎⁎ −0.435 - 0.665 0.164–0.584⁎⁎
inconsistent concerning gender, desire for social distance increases with age in most studies [10]. As it was shown here, the latter also holds true for SSD. Educational level was negatively associated with social distance in a number of studies [10,24], whereas we didn't find an association with social distance towards people affected by SSD. In contrast to the present study, personal experience and contact with persons afflicted was also found to be negatively associated with social distance [10]. It has to be kept in mind that all these previous studies were not related to SSD. Several methodological aspects have to be considered when interpreting and evaluating our findings. Analyses are based on a carefully drawn national probability sample. Measurement of public stigma covers different, theoretically founded components (stereotype, emotional reactions, and desire for social distance) and uses validated instruments. It can be criticized that we used a broad and unspecific stigma concept because some SSD specific stereotypes may be missing (e.g. shamming). We decided to use unspecific measures to get results that are comparable with previous studies. In terms of the sample, about 52% of the selected eligible persons refused to participate or were not available. Although, a response rate of 48% is quite good for a national telephone survey [25], results may be threatened by selection bias. However, comparison of sociodemographic characteristics in the sample with official statistics indicates that selection bias in our study is limited. Even though the use of vignettes as a stimulus is widespread in stigma research, they have to be short to be included into surveys. SSD is a complex disorder with three diagnostic criteria [1] and it is disputable if this disorder is adequately represented in short vignettes like ours. Furthermore, SSD is polymorphic and our analyses are restricted to two vignettes. In addition, we cannot rule out that social desirability may play a role when answering questions about stigma. However, we do not think that this affects our results concerning differences between the vignettes, differences between SSD and depression, and predictors of SSD stigma. Finally, we cannot exclude that the patient characteristic of being a psychologically suffering person in need of help may primarily account for the amount of stigma found in the general population. However, observed differences in public stigma between SSD and depression suggest that the specific content of the vignettes besides the general characteristic as a suffering person influences the participants' response. Results indicate that there is public stigma towards people affected by SSD in Germany. The magnitude is lower in terms of stereotypes and desire for social distance compared to depression, while there are no differences in negative emotional reactions between depression stigma
Table 4 Linear regression: associations with desire for social distance from someone with a somatic symptom disorder (Vignette A, pain without somatic disease).
Gender (ref. male) Age Level of education Experience with disorder Own affliction: yes (ref. no) Contact to someone with SSD (ref. no) Stereotypes In need of help Unpredictable Scary Sensitive Negative emotional reaction scale R2
0.342 0.058 −0.010
p < 0.05. p < 0.01. ⁎⁎⁎ p < 0.001.
Vignettes A and B pooled. Mann-Whitney-U. a stereotypes and emotional reaction single items ranging from 1 ‘totally disagree’ to 4 ‘totally agree’. b emotional reaction scale ranging from 3 to 12, comprised of 3 items (sum score). c desire for social distance single items ranging from 1 ‘totally agree’ to 4 ‘totally disagree’. d desire for social distance scale comprised of 7 items, total score ranging from 7 to 28 (sum score).
95% CI
95% CI
⁎⁎
⁎⁎
Βeta
Βeta
⁎
⁎
B
B
p < 0.05. p < 0.01. ⁎⁎⁎ p < 0.001. ⁎
⁎⁎
without a medical diagnosis [15]. However, our results do not support this assumption, as the magnitude of stigma did not differ between the vignettes with and without a medical diagnosis. There are quite many studies analyzing predictors of public stigma in general and the desire for social distance in particular, with a focus on mental illness (for a review please see [10]). While results are 74
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and SSD stigma. From population based attitude research in psychiatry it is known that public stigma can have important consequences for those afflicted. Public stigma is positively associated with self-stigma [26] and even with the prevalence of suicide [27] while it is negatively linked to self-rated health [28] and help-seeking behavior [29,30]. Reducing SSD stigma may help to prevent chronification because stigma can be a barrier, which may impede diagnosis of somatoform and related disorders [11]. In this regard, more studies are needed analyzing public SSD stigma to understand the mechanisms and to learn more about differences between symptoms by using other vignettes.
[5] J. Katz, B.N. Rosenbloom, S. Fashler, Chronic pain, psychopathology, and DSM-5 somatic symptom disorder, Can. J. Psychiatr. 60 (2015) 160–167. [6] B.G. Link, J.C. Phelan, Conceptualizing stigma, Annu. Rev. Sociol. 27 (2001) 363–385. [7] O.v.d. Knesebeck, E. Mnich, M.C. Angermeyer, et al., Changes in depression stigma after the Germanwings crash - Findings from German population surveys, J. Affect. Disord. 186 (2015) 261–265. [8] A.C. Makowski, E. Mnich, J. Ludwig, et al., Changes in beliefs and attitudes towards people with depression and schizophrenia – results a public campaign in Germany, Psych Res 237 (2016) 271–278. [9] M.C. Angermeyer, G. Schomerus, State of the art of population-based attitude research on mental health: a systematic review, Epidemiol Psychiatr Sci 26 (2017) 252–264. [10] M.C. Angemeyer, S. Dietrich, Public beliefs about and attitudes towards people with mental illness: a review of population studies, Acta Psychiatr. Scand. 113 (2006) 163–179. [11] A.M. Murray, A. Toussaint, A. Althaus, B. Löwe, The challenge of diagnosing nonspecific, functional, and somatoform disorders: a systematic review of barriers to diagnosis in primary care, J. Psychosom. Res. 80 (2016) 1–10. [12] M. Freidl, S. Piralic Spitzl, W. Prause, et al., The stigma of mental illness: anticipation and attitudes among patients with epileptic, dissociative or somatoform pain disorder, Int Rev Psychiatry 19 (2007) 123–129. [13] M. Freidl, S. Piralic Sptzl, N. Grohe, et al., Zusammenhang zwischen Stigmabefürchtung, depressiver und Angstsymptomatik bei Patienten mit somatoformer Schmerzstörung, Psychiat Praxis 39 (2012) 263–266. [14] L. Taft Th Keefer, C. Leonhard, et al., Impact of perceived stigma on inflammatory bowel disease patient outcomes, Inflamm. Bowel Dis. 15 (2009) 1224–1232. [15] K.J. Looper, L.J. Kirmayer, Perceived stigma in functional somatic syndromes and comparable medical conditions, J. Psychosom. Res. 57 (2004) 373–378. [16] P. Hüsing, B. Löwe, A. Toussaint, Comparing the diagnostic concepts of ICD-10 somatoform disorders and DSM-5 somatic symptom disorders in patients from a psychosomatic outpatient clinic, J. Psychosom. Res. 113 (2018) 74–80. [17] L. Kish, A procedure for objective respondent selection within the household, J. Am. Stat. Assoc. 44 (1949) 380–387. [18] O.v.d. Knesebeck, C. Kofahl, A. Makowski, Differences in depression stigma towards ethnic and socio-economic groups in Germany – exploring the hypothesis of double stigma, J. Affect. Disord. 208 (2017) 82–86. [19] M.C. Angermeyer, H. Matschinger, The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder, Acta Psychiatr. Scand. 108 (2003) 304–309. [20] B.G. Link, F.T. Cullen, J. Frank, et al., The social rejection of former mental patients: understanding why labels matter, Am. J. Sociol. 92 (1987) 1461–1500. [21] E.S. Bogardus, Measuring social distance, J. Appl. Sociol. 9 (1925) 299–308. [22] M.C. Angermeyer, H. Matschinger, G. Schomerus, Attitudes towards psychiatric treatment and people with mental illness: changes over two decades, Br. J. Psychiatry 203 (2013) 146–151. [23] A.C. Makowski, E. Mnich, M.C. Angermeyer, et al., Sex differences in attitudes towards females with eating disorders, Eat. Behav. 16 (2015) 78–83. [24] O.v.d. Knesebeck, M.C. Angermeyer, C. Kofahl, et al., Education and the public's desire for social distance towards people with depression and schizophrenia – the contribution of emotional reactions and causal attributions, Int J Soc Psychiatry 60 (2014) 468–473. [25] R. Curtin, S. Presser, E. Singer, Changes in telephone survey nonresponse over the past quarter century, Public Opin Quart 69 (2005) 87–98. [26] S. Evans-Lacko, E. Brohan, R. Mojtabai, et al., Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries, Psychol. Med. 42 (2012) 1741–1752. [27] G. Schomerus, S. Evans-Lacko, N. Rüsch, et al., Collective levels of stigma and national suicide rates in 25 European countries, Epidemiol Psychiatr Sci 24 (2015) 166–171. [28] J. Alvarez-Galvez, L. Salvador-Carulla, Perceived discrimination and self-rated health in Europe: evidence from the European Social Survey (2010), PLoS One 8 (2013) e74252. [29] K.M. Griffiths, D.A. Crisp, A.F. Jorm, et al., Does stigma predict a belief in dealing with depression alone? J. Affect. Disord. 132 (2011) 413–417. [30] S. Clement, O. Schauman, T. Graham, et al., What is the impact of mental healthrelated stigma on help-seeking? A systematic review of quantitative and qualitative studies, Psychol. Med. 45 (2015) 11–27.
Declarations of interest None. Acknowledgement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Appendix A A.1. Vignette A (pain without somatic disease) Since one year, 32 years old/62 years* old Anja/Anton* S. has been suffering from constant piercing pain in the left side of her body, in her hand, arm, leg, and in her feet. She feels very restricted in her daily life. Medical examinations have provided no explanation for her complaints. Mrs. S has an intense fear for her health and is thinking about her complaints all the time. She is constantly surfing the internet to learn more about her troubles. A.2. Vignette B (fatigue with cured somatic disease) For more than six months, 32 years old/62 years old * Monika/ Martin* E. has been suffering from total exhaustion, accompanied by chest pain, pain in her muscles and her shoulder. After a fully cured inflammation of the heart muscle eight months ago, she is continuously thinking that her complaints indicate a severe heart disease. According to a current medical examination, her heart is in a good condition. She still has intense fear regarding her health and her complaints. Mrs. E. is investing a lot of time and energy on her health concerns. ⁎ Gender and age of the person in the vignettes were systematically varied. References [1] J.E. Dimsdale, F. Creed, J. Escobar, et al., Somatic symptom disorder: an important change in DSM, J. Psychosom. Res. 75 (2013) 223–228. [2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, DSM-5, American Psychiatric Publishing, Arlington, 2013. [3] P. Henningsen, S. Zipfel, H. Sattel, et al., Management of functional somatic syndromes and bodily distress, Psychother. Psychosom. 87 (2018) 12–31. [4] A. Frances, The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill, BMJ 346 (2013) f1580.
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Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores
Public stigma towards individuals with somatic symptom disorders – Survey results from Germany
T
Olaf von dem Knesebecka, , Marco Lehmannb, Bernd Löweb, Anna C. Makowskia ⁎
a b
Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg 20146, Germany Institute and Outpatients Clinic for Psychosomatic Medicine and Psychotherapy, Martinistr 52, Hamburg 20146, Germany
ARTICLE INFO
ABSTRACT
Keywords: Somatic symptom disorder Public stigma Social distance Depression
Objective: The study aims to investigate (1) the magnitude of public stigma towards individuals with somatic symptom disorder (SSD), (2) differences in public stigma between SSD and depression, and (3) predictors of social distance towards individuals with SSD. Methods: Analyses are based on a national telephone survey in Germany (N = 1004). Two vignettes with symptoms of SSD were used. Vignettes differed regarding main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Stigma was measured by stereotypes, negative emotional reactions, and desire for social distance. Results: There were no significant differences in public stigma regarding type of symptom and existence of an earlier somatic disease. Two of three components of public stigma under study (stereotypes and desire for social distance) showed higher values in case of depression compared to SSD (both vignettes pooled). Age and negative emotional reactions were positively associated with desire for social distance in case of both SSD vignettes, whereas associations with stereotypes and experience (own affliction and contact to persons afflicted) were inconsistent. Education was not associated with social distance towards people with SSD. Conclusions: Results indicated public stigma towards people affected by SSD in Germany. Compared with depression, SSD stigma was lower in most components. Magnitude of SSD stigma was similar, irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Reducing SSD stigma could help to improve illness behaviour and prevent chronification.
1. Introduction A somatic symptom disorder (SSD) is defined on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms [1]. In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2], the somatoform disorder has been replaced by the category of SSD. In the course of this change, the medically unexplained criterion of the somatization disorder was omitted, whereas positive psychobehavioral criteria, namely high health anxiety, excessive symptom preoccupation, excessive health worry, and maladaptive illness behavior were included [3]. Stigma is one important aspect in the debate about the rationale and consequences of this categorical change [1,4,5]. However, studies analyzing stigma related to SSD are rare. Stigma can be defined as a process in which labeling, stereotyping, status loss and discrimination co-occur in a situation where power is exercised [6]. Public stigma is usually assessed by different beliefs
⁎
endorsed by the general population, such as the ascription of attributes (stereotypes), emotional response upon meeting an afflicted person (e.g. anger or fear) or the desire to socially distance oneself [7,8]. A recent review revealed that almost half of all public attitude research in Western countries focuses on depression [9]. In terms of predictors of public mental illness stigma, many studies focused on sociodemographic characteristics like gender, age and education yielding inconsistent results (for review please see [10]). Experiences with mental illness, i.e. being or having been afflicted by the mental illness or having personal contact with people suffering from mental illness, has been found to be negatively associated with stigma [10]. Public stigma imposes a great burden on those affected with negative consequences for their health and help-seeking behavior. Stigma can also be a barrier, which may impede diagnosis of somatoform and related disorders [11]. There are few studies analyzing stigma related to SSD or somatoform disorders but these primarily focus on perceived or anticipated
Corresponding author. E-mail address: [email protected] (O. von dem Knesebeck).
https://doi.org/10.1016/j.jpsychores.2018.10.014 Received 24 May 2018; Received in revised form 12 September 2018; Accepted 24 October 2018 0022-3999/ © 2018 Published by Elsevier Inc.
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stigma, and not on public stigma. In these studies, patients are asked whether they believe that they are stigmatized because of their disorder. Results indicate that the large majority of patients reports perceived stigma [12–14]. For example, in an Austrian study, about 3/4 of patients with a somatoform disorder worry that they are stigmatized because of their disorder [13]. A Canadian study found that there are greater levels of perceived stigma among patients with functional somatic symptoms compared to those with medical diagnoses [15]. However, it is unclear, to what extent the general public actually holds stigmatizing beliefs towards people affected by SSD and there is nothing known about possible predictors of public SSD stigma. In fact, the characteristics of functional somatic symptoms primarily focus on the inexplicability of the symptoms in medical terms. In contrast, the characteristics of SSD primarily focus on psychological concerns, anxiety, and symptom related behavior. Despite the fact that the patient groups with SSD and FSS substantially overlap [16], we cannot expect the same level of stigma if patient characterization is grossly different between the two classifications. Against this background, and based on a national population survey in Germany, the analyses will focus on the following research questions: What is the magnitude of public stigma (i.e. stereotypes, negative emotional reactions, and desire for social distance) towards individuals with SSDs? Are there differences in public stigma between SSD and depression? Are sociodemographic and experience-related factors predictors of social distance towards individuals with SSDs?
Table 1 Sociodemographic characteristics of the sample compared to official German statistics of the general population.
Sex (female, %) Level of education (%) ≤ 9 years 10 years ≥ 12 years Age (groups, %) 18–24 25–39 40–59 60–64 > 65
Vignette A (n = 499)
Vignette B (n = 505)
Sample (N = 1004)
Official statistics
p⁎
52.9
50.9
51.9
50.7a
0.73
35.7 30.2 34.2
33.6 32.0 34.4
34.7 31.1 34.2
34.2b 32.0b 33.5b
0.44
10.4 19.9 32.7 9.6 27.3
8.3 22.8 34.9 9.7 24.4
9.4 21.4 33.8 9.7 25.7
9.2c 22.5c 35.6c 7.6c 25.1c
0.19
a Federal Office of Statistics: Statistical Yearbook 2017, p 26 (Available online: https://www.destatis.de/DE/Publikationen/StatistischesJahrbuch/ StatistischesJahrbuch.html. Last accessed April 23, 2018). b Federal Office of Statistics: Statistical Yearbook 2017, p 84. c Federal Office of Statistics: Statistical Yearbook 2017, p 31 ⁎ χ2-test: sample against official German statistics.
symptom and existence of an earlier somatic disease. Vignettes were additionally varied according to gender (female vs. male) and age (32 years vs. 62 years), resulting in eight different vignettes that each were randomly assigned to about 125 respondents (i.e. about 12.5% of the sample). A trained speaker audio-recorded the vignettes. To neutralize possible interviewer effects, the files were directly played to the respondents from the computer via telephone line. For a comparison with public stigma towards individuals with a depression, we additionally use a preceding national telephone survey (N = 505) conducted in 2016 (for details please see [18]). In this survey, we also used a vignette, in this case with typical signs and symptoms suggestive of a depression.
2. Methods 2.1. Study design and sample Data from a national telephone survey via CATI (Computer-Assisted Telephone Interview) conducted in November and December 2017 in Germany were used for the analyses. Sample consisted of adults aged 18 and older, living in private households. About 70% of the sample was drawn from all registered private telephone numbers at random, additional computer-generated numbers also allowed for inclusion of exdirectory households (landline numbers). The other 30% of the sample consisted of randomly generated mobile phone numbers (Random Digit Dialing, RDD). For a random selection of participants in the households, the Kish-Selection Grid was applied [17]. Among mobile users, target person was the owner or main user of the mobile device. After having been informed that participation in the study is voluntary and that withdrawal from the study is possible at any time, 1004 individuals participated, reflecting a response rate of about 48.3%. Data collection procedure was approved by the Ethics Commission of the Medical Association in Hamburg (No. PV3707). Comparison of sociodemographic characteristics in the sample with official statistics indicates that distribution of age, gender, and education is similar to the general adult population in Germany (Table 1).
2.3. Instruments Three elements of the stigma process were assessed [6]: (1) characteristics ascribed to the person with SSD in the vignette (stereotypes), (2) negative emotional reactions, and (3) desire for social distance. Stereotypes were assessed using four items derived from a list of Angermeyer and Matschinger [19]. On a four-point Likert scale, respondents were asked to indicate to what extent they agree or disagree with the following statements: “The person described in the vignette is…” “…in need of help”, “…unpredictable”, “…scary”, “…sensitive”. Negative emotional reactions towards the person in the vignette were assessed by three items (angry, annoyed, and incomprehension). The items were taken from an instrument developed by Angermeyer and Matschinger [19]. Respondents were asked to agree or disagree to the respective emotional reaction on a four point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). We computed a sum score for emotional reactions ranging from 3 to 12; Cronbach's Alpha of the scale is 0.73. Desire for social distance was measured by a scale developed by Link et al. [20]. It is a modified version of the Bogardus Desire for Social Distance scale [21]. It includes seven items addressing various social relationships: tenant, co-worker, neighbor, child carer, in-law, and person one would recommend for a job or person of the same social circle. Respondents were asked to specify whether they would accept the described person in the vignette for each social relationship on a four-point Likert scale (ranging from 1 ‘totally agree’ to 4 ‘totally disagree’). A sum score (range from 7 to 28) was computed to assess the respondents' overall desire for social distance. Cronbach's Alpha of the Desire for Social Distance scale is 0.83.
2.2. Vignettes At the beginning of the interview, a vignette with signs and symptoms suggestive of a SSD was presented to the respondents in the survey. Two different vignettes were developed with the input of clinicians (see Appendix). Both vignettes show cases of a SSD according to DSM-5 [2]. The first sentence of both vignettes consists of information to fulfill both, the A criterion (burdensome somatic symptom) and the C criterion (persistence of symptom burden) of SSD. The subsequent sentences give information regarding the B criterion concerning excessive thoughts about the severity of the symptoms, severe anxiety about ones health and the symptoms, and excessive symptom related behavior. Vignette A shows a case of a SSD with pain as the main symptom without a comorbid somatic disease. In contrast, vignette B shows a case with fatigue as the main symptom and an earlier severe somatic disease. Thus, the two vignettes differ in terms of main type of 72
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In terms of predictors of social distance, previous studies indicate that sociodemographic and experience-related factors play an important role [10]. Age, gender, and education (highest educational degree) are introduced as sociodemographic characteristics. To asses respondents experience with symptoms described in the vignette, they were asked whether they themselves ever were afflicted by similar symptoms (yes vs. no). Moreover, they were asked whether they have or had personal contact to a person afflicted (yes vs. no). About 22% of the respondents reported that they are or were afflicted by similar symptoms described in vignette A (pain without somatic disease). Respective prevalence in case of vignette B (fatigue with earlier somatic disease) is 26%. Almost half of the respondents (47%) had personal contact to an individual with symptoms like the person in vignette A. This rate is higher in case of vignette B (62%).
Table 2 Stigmatizing attitudes towards a person with somatic symptom disorder depending on clinical picture presented in the vignette (means, standard deviations, and significances).
Stereotypesa The person in the vignette is… …in need of help …unpredictable …scary …sensitive Emotional reactionsa Upon meeting this person… …I react angrily. …I feel annoyed. …I react with incomprehension. Scale emotional reactionsb Desire for social distance with regard to the following relationshipsc Tenant Colleague Neighbor Childcare In-law Introduce friend Recommend for a job Desire for social distance scaled
2.4. Analyses To analyze the magnitude of public stigma (stereotypes, negative emotional reactions, and desire for social distance), means of the items and scales are compared and Mann-Whitney tests are calculated. To examine predictors of social distance, multiple linear regression analyses are conducted. Sociodemographic characteristics of the respondents (age, gender, and education), experience-related factors (affliction, contact to persons afflicted) as well as stereotypes and emotional reactions are introduced as predictors. Regression coefficients, 95%-confidence intervals, significances, and explained variances (R2) are documented in the tables.
Vignette A (pain without somatic disease, n = 499)
Vignette B (fatigue with previous somatic disease, n = 505)
p⁎
3.19 1.98 1.63 3.27
(0.72) (0.84) (0.73) (0.68)
3.13 1.99 1.58 3.27
(0.72) (0.81) (0.74) (0.68)
0.12 0.85 0.09 0.67
1.49 1.91 1.68 5.09
(0.70) (0.89) (0.81) (1.91)
1.52 1.86 1.68 5.07
(0.73) (0.83) (0.79) (1.92)
0.55 0.52 0.92 0.89
2.22 (0.98) 1.58 (0.69) 1.51 (0.65) 2.58 (0.97) 1.92 (0.88) 2.00 (0.83) 2.33 (0.93) 14.47 (3.24)
2.27 (0.97) 1.58 (0.71) 1.60 (0.76) 2.58 (0.96) 2.00 (0.92) 2.12 (0.96) 2.35 (0.92) 14.80 (3.39)
0.32 0.89 0.34 0.71 0.34 0.07 0.47 0.26
Mann-Whitney-U test. stereotypes and emotional reaction single items ranging from 1 ‘totally disagree’ to 4 ‘totally agree’. b emotional reaction scale ranging from 3 to 12, comprised of 3 items (sum score). c desire for social distance single items ranging from 1 ‘totally agree’ to 4 ‘totally disagree’. d desire for social distance scale comprised of 7 items, total score ranging from 7 to 28 (sum score). ⁎
a
3. Results Table 2 shows the stigmatizing attitudes (stereotypes, emotional reactions, and desire for social distance) towards the two cases of SSD. There are no significant differences between the two vignettes, i.e. magnitude of public stigma is similar irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). As there are no differences in stigma between the two SSD vignettes, these are pooled for the comparison with a depression vignette (Table 3). Stereotypes ascribed to the person in the vignette differ between SSD and depression. In case of an individual with depressive symptoms, respondents more often agreed that such a person is in need of help, is unpredictable, scary, and sensitive. In terms of negative emotional reactions, there are no significant differences between the SSD vignettes and depression, whereas desire for social distance is significantly more pronounced when the respondents are confronted with someone with a depression. Table 4 shows the associations of desire for social distance with sociodemographic characteristics of the respondents (age, gender, and education), experience-related factors (affliction, contact to persons afflicted) as well as stereotypes and emotional reactions for the SSD vignette A (pain without somatic disease). Higher age is associated with increased desire for social distance. Moreover, there is a stronger desire for social distance among those respondents who show negative emotional reactions or who agree that the person in vignette A is in need of help, unpredictable, or scary. The stereotype ‘sensitivity’ is associated with a decrease of social distance. In terms of vignette B (fatigue with previous somatic disease), desire for social distance towards persons with SSD is more pronounced among older respondents and among those who show negative emotional reactions and who agree that a person with SSD is scary (Table 5). Contrary, social distance significantly decreases when respondents report that they were afflicted by similar symptoms themselves.
4. Discussion To the best of our knowledge, this is the first study analyzing public stigma towards people affected by SSD. Using two different vignettes in a German general population survey, our results show that the magnitude of public stigma is similar in terms of stereotypes, emotional reactions and desire for social distance, irrespective of main type of symptom (pain vs. fatigue) and existence of an earlier somatic disease (yes vs. no). Two of three components of public stigma under study (i.e. stereotypes and desire for social distance) show higher values in case of a person affected by depression compared to SSD (both vignettes pooled). Age and negative emotional reactions are positively associated with desire for social distance in case of both SSD vignettes, whereas associations with stereotypes and experience (own affliction and contact to persons afflicted) are inconsistent. Education is not associated with social distance towards people with SSD. As stereotypes, negative emotional reactions and desire for social distance were also assessed in a number of other German studies, our results can be compared with previous findings. Angermeyer et al. [22] compared the magnitude of public stigma across different mental disorders. Their results indicate that people with depression are confronted with lower levels of stigma than those with schizophrenia or alcohol dependence. Thus, compared with other mental illnesses, SSD stigma presented here is rather low. Compared to a German study [23], analyzing stigma in case of eating disorders (bulimia nervosa and anorexia nervosa), SSD stigma, however, is more pronounced. It can be assumed that people having persistent somatic symptoms and a medical diagnosis are less stigmatized than people having somatic symptoms 73
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Table 3 Stigmatizing attitudes towards persons with somatic symptom disorders and depression (means, standard deviations, and significances). Somatic Symptom Disorders (n = 1004)⁎
Depression (n = 505)
Table 5 Linear regression: associations with desire for social distance from someone with a somatic symptom disorder (Vignette B, fatigue with previous somatic disease).
p⁎⁎
Stereotypesab The person in the vignette is… …in need of help 3.16 (0.72) 3.34 (0.72) …unpredictable 1.99 (0.82) 2.48 (0.88) …scary 1.61 (0.74) 1.96 (0.84) …sensitive 3.27 (0.68) 3.36 (0.70) Emotional reactions a Upon meeting this person… …I react angrily. 1.51 (0.71) 1.48 (0.62) …I feel annoyed. 1.88 (0.86) 1.91 (0.86) …I react with 1.68 (0.80) 1.72 (0.83) incomprehension. Scale emotional reactions b 5.08 (1.91) 5.10 (1.82) Desire for Social Distance with regard to the following relationshipsc Tenant 2.24 (0.97) 2.43 (0.98) Colleague 1.58 (0.70) 1.62 (0.71) Neighbor 1.56 (0.71) 1.66 (0.73) Childcare 2.58 (0.96) 3.03 (0.88) In-law 1.96 (0.90) 2.32 (0.96) Introduce a friend 2.06 (0.93) 2.29 (0.91) Job recommendation 2.34 (0.93) 2.56 (0.88) Desire for Social Distance 14.33 (4.31) 15.77 (4.04) Scaled
Gender (ref. male) Age Level of education Experience with disorder Own affliction: yes (ref. no) Contact to someone with SSD (ref. no) Stereotypes In need of help Unpredictable Scary Sensitive Negative emotional reaction scale R2
< 0.001 < 0.001 < 0.001 0.003 0.53 0.91 0.81 0.88 0.001 0.15 0.004 < 0.001 < 0.001 0.009 < 0.001 < 0.001
0.222 0.031 0.359
0.027 0.143 0.072
−0.529 - 0.973 0.010–0.051⁎⁎ −0.108 - 0.827
−0.315 0.340
−0.032 0.041
−1.235 - 0.604 −0.419 - 1.099
0.735 0.700 1.039 −0.626 0.282 0.175
0.131 0.143 0.184 −0.103 0.128
0.226–1.243⁎⁎ 0.233–1.166⁎⁎ 0.480–1.598⁎⁎⁎ −1.190 - -0.061⁎ 0.064–0.500⁎
0.039 0.239 −0.002
−0.409 - 1.093 0.037–0.080⁎⁎⁎ −0.480 - 0.460
−0.891 0.543
−0.089 0.061
−1.744 - -0.038⁎ −0.225 - 1.311
−0.141 0.309 1.466 0.115 0.374 0.226
−0.024 0.057 0.244 0.019 0.167
−0.669 - 0.387 −0.204 - 0.822 0.874–2.036⁎⁎⁎ −0.435 - 0.665 0.164–0.584⁎⁎
inconsistent concerning gender, desire for social distance increases with age in most studies [10]. As it was shown here, the latter also holds true for SSD. Educational level was negatively associated with social distance in a number of studies [10,24], whereas we didn't find an association with social distance towards people affected by SSD. In contrast to the present study, personal experience and contact with persons afflicted was also found to be negatively associated with social distance [10]. It has to be kept in mind that all these previous studies were not related to SSD. Several methodological aspects have to be considered when interpreting and evaluating our findings. Analyses are based on a carefully drawn national probability sample. Measurement of public stigma covers different, theoretically founded components (stereotype, emotional reactions, and desire for social distance) and uses validated instruments. It can be criticized that we used a broad and unspecific stigma concept because some SSD specific stereotypes may be missing (e.g. shamming). We decided to use unspecific measures to get results that are comparable with previous studies. In terms of the sample, about 52% of the selected eligible persons refused to participate or were not available. Although, a response rate of 48% is quite good for a national telephone survey [25], results may be threatened by selection bias. However, comparison of sociodemographic characteristics in the sample with official statistics indicates that selection bias in our study is limited. Even though the use of vignettes as a stimulus is widespread in stigma research, they have to be short to be included into surveys. SSD is a complex disorder with three diagnostic criteria [1] and it is disputable if this disorder is adequately represented in short vignettes like ours. Furthermore, SSD is polymorphic and our analyses are restricted to two vignettes. In addition, we cannot rule out that social desirability may play a role when answering questions about stigma. However, we do not think that this affects our results concerning differences between the vignettes, differences between SSD and depression, and predictors of SSD stigma. Finally, we cannot exclude that the patient characteristic of being a psychologically suffering person in need of help may primarily account for the amount of stigma found in the general population. However, observed differences in public stigma between SSD and depression suggest that the specific content of the vignettes besides the general characteristic as a suffering person influences the participants' response. Results indicate that there is public stigma towards people affected by SSD in Germany. The magnitude is lower in terms of stereotypes and desire for social distance compared to depression, while there are no differences in negative emotional reactions between depression stigma
Table 4 Linear regression: associations with desire for social distance from someone with a somatic symptom disorder (Vignette A, pain without somatic disease).
Gender (ref. male) Age Level of education Experience with disorder Own affliction: yes (ref. no) Contact to someone with SSD (ref. no) Stereotypes In need of help Unpredictable Scary Sensitive Negative emotional reaction scale R2
0.342 0.058 −0.010
p < 0.05. p < 0.01. ⁎⁎⁎ p < 0.001.
Vignettes A and B pooled. Mann-Whitney-U. a stereotypes and emotional reaction single items ranging from 1 ‘totally disagree’ to 4 ‘totally agree’. b emotional reaction scale ranging from 3 to 12, comprised of 3 items (sum score). c desire for social distance single items ranging from 1 ‘totally agree’ to 4 ‘totally disagree’. d desire for social distance scale comprised of 7 items, total score ranging from 7 to 28 (sum score).
95% CI
95% CI
⁎⁎
⁎⁎
Βeta
Βeta
⁎
⁎
B
B
p < 0.05. p < 0.01. ⁎⁎⁎ p < 0.001. ⁎
⁎⁎
without a medical diagnosis [15]. However, our results do not support this assumption, as the magnitude of stigma did not differ between the vignettes with and without a medical diagnosis. There are quite many studies analyzing predictors of public stigma in general and the desire for social distance in particular, with a focus on mental illness (for a review please see [10]). While results are 74
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and SSD stigma. From population based attitude research in psychiatry it is known that public stigma can have important consequences for those afflicted. Public stigma is positively associated with self-stigma [26] and even with the prevalence of suicide [27] while it is negatively linked to self-rated health [28] and help-seeking behavior [29,30]. Reducing SSD stigma may help to prevent chronification because stigma can be a barrier, which may impede diagnosis of somatoform and related disorders [11]. In this regard, more studies are needed analyzing public SSD stigma to understand the mechanisms and to learn more about differences between symptoms by using other vignettes.
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Declarations of interest None. Acknowledgement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Appendix A A.1. Vignette A (pain without somatic disease) Since one year, 32 years old/62 years* old Anja/Anton* S. has been suffering from constant piercing pain in the left side of her body, in her hand, arm, leg, and in her feet. She feels very restricted in her daily life. Medical examinations have provided no explanation for her complaints. Mrs. S has an intense fear for her health and is thinking about her complaints all the time. She is constantly surfing the internet to learn more about her troubles. A.2. Vignette B (fatigue with cured somatic disease) For more than six months, 32 years old/62 years old * Monika/ Martin* E. has been suffering from total exhaustion, accompanied by chest pain, pain in her muscles and her shoulder. After a fully cured inflammation of the heart muscle eight months ago, she is continuously thinking that her complaints indicate a severe heart disease. According to a current medical examination, her heart is in a good condition. She still has intense fear regarding her health and her complaints. Mrs. E. is investing a lot of time and energy on her health concerns. ⁎ Gender and age of the person in the vignettes were systematically varied. References [1] J.E. Dimsdale, F. Creed, J. Escobar, et al., Somatic symptom disorder: an important change in DSM, J. Psychosom. Res. 75 (2013) 223–228. [2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, DSM-5, American Psychiatric Publishing, Arlington, 2013. [3] P. Henningsen, S. Zipfel, H. Sattel, et al., Management of functional somatic syndromes and bodily distress, Psychother. Psychosom. 87 (2018) 12–31. [4] A. Frances, The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill, BMJ 346 (2013) f1580.
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