|Year : 2019 | Volume
| Issue : 1 | Page : 2-6
A study to assess the relationship between stigma and expressed emotion among the primary care givers of persons with schizophrenia attending outpatient department of Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur
Rinki Ghosh1, Nurnahar Ahmed2
1 M.Sc Nursing, LGBRIMH, Tezpur, Assam, India
2 Assistant Professor (I/C), Department of Psychiatric Nursing, LGBRIMH, Tezpur, Assam, India
|Date of Web Publication||14-Oct-2019|
Mrs. Rinki Ghosh
LGBRIMH, Tezpur, Assam
Source of Support: None, Conflict of Interest: None
Background: Mental illness is a condition that impacts a person's thinking, feeling or mood and may affect his or her ability to relate to others and function on a daily basis. Among various types of mental illnesses schizophrenia is common disorder affecting approximately 1% of any given adult population. Stigma surrounding schizophrenia restraints the patient and family members to access the treatment facilities and type of support they need to manage their illness. It can also disturb the family environment which can often give rise to expressed emotion. Expressed emotion refers to a global index of particular emotions, attitudes and behaviours expressed by relatives of a family member diagnosed with schizophrenia. Aims and Objectives: The aim of the study was to assess the relationship between stigma and expressed emotion among the primary care givers of persons with schizophrenia. Materials and Methods: Descriptive co relational research design was used. The sample comprised of 60 primary caregivers of persons with schizophrenia attending OPD of LGBRIMH, Tezpur which was selected by using purposive sampling technique. Two standardized tool (Stigma subscale of Family Interview Schedule and Family Attitude Scale) and socio demographic data sheet was used for patient and primary care giver. Results: Finding showed majority of the sample i.e. 65% (n = 39) obtained the stigma score below 10.83 (mean score) and only 35% (n = 21) obtained the stigma score above10.83 (mean score).This finding showed that majority of the primary care givers has low stigma having a patient with psychiatric illness in their family. It was also showed that majority of the sample i.e. 66.7% have obtained expressed emotion score below 29.68 (mean score) and 33.3% have obtained expressed emotion score above 29.68 (mean score).This finding showed that the majority of the primary care givers has low expressed emotion towards a family member having schizophrenia. There was significant positive correlation found between stigma and expressed emotion among the primary care givers of persons with schizophrenia (calculated value was found to be 0.587 which was higher than the tabulated value at 0.01 level of significance). Conclusion: It showed that if stigma increases, the expressed emotion among the primary care givers towards the patient also increases.
Keywords: Expressed emotion, primary care givers, schizophrenia, stigma
|How to cite this article:|
Ghosh R, Ahmed N. A study to assess the relationship between stigma and expressed emotion among the primary care givers of persons with schizophrenia attending outpatient department of Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur. Indian J Psy Nsg 2019;16:2-6
|How to cite this URL:|
Ghosh R, Ahmed N. A study to assess the relationship between stigma and expressed emotion among the primary care givers of persons with schizophrenia attending outpatient department of Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health, Tezpur. Indian J Psy Nsg [serial online] 2019 [cited 2019 Dec 5];16:2-6. Available from: http://www.ijpn.in/text.asp?2019/16/1/2/269163
| Introduction|| |
While there is a debate over how to define mental illness, it is generally accepted that mental illnesses are real and involve disturbances of thought, experience, and emotion serious enough to cause functional impairment in people, making it more difficult for them to sustain interpersonal relationships and carry on their jobs, and sometimes leading to self-destructive behavior and even suicide. According to the World (Mental) Health Report 2001, about 24 million people worldwide suffer from schizophrenia. Approximately 1% of the population worldwide will suffer from schizophrenia in their lifetime, with the onset of the illness occurring usually in late adolescence or early adulthood. However, despite of advancing treatment modalities, relapse is reported high. There are several factors which lead to increased numbers of relapse rates in schizophrenia. Among them, stigma and expressed emotion (EE) are the most common. The most established definition regarding stigma is written by Goffman (1963) in his seminar work: Stigma: Notes on the Management of Spoiled Identity. He states that stigma is “an attribute that is deeply discrediting” that reduces someone “from a whole and usual person to a tainted, discounted one.” The stigmatized, thus, are perceived as having a “spoiled identity.” Pawar et al. conducted a study on mental illness stigma in India to measure stigma perceived by patients and caregivers of the mentally ill where result showed high levels of stigma among the patients and caregivers of mentally ill. As stigma plays a significant role in the life of people with schizophrenia and their family members, it can also lead to burden and decrease in quality of life of the persons of those families which can ultimately landed to EE within the family.
EE is currently among the most thoroughly investigated psychosocial research constructs in psychiatry. The concept and measurement of the EE within families were developed in the 1960s, initially for use in schizophrenia. EE refers to a global index of particular emotions, attitudes, and behaviors expressed by relatives about a family member diagnosed with psychiatric illness. George Brown described five components of EE which includes emotional over-involvement, critical comments, hostility, positive remarks, and warmth. The impact of stigma and EE leads to increased number of relapses which further leads to burden among the family members. Tantawy et al. have done a study to evaluate stigma and negative EEs and their burden among patients with severe psychiatric illnesses and among their family members where result showed a high level of stigma and discrimination and frequency of high EE was significantly higher than that of low EE. Stigma and EE are associated with higher scores in Brief Psychiatric Rating Scale, increased numbers of relapses. Patients with severe psychiatric illnesses are under considerable burden due to stigma and negative EE directed at them. The study conducted by Rishi on causes for delay and underutilization of psychiatric treatment in India where the result found that lack of awareness about the psychiatric treatment, cultural myth about the illness and stigma was found to be associated significantly with delay and underutilization of psychiatric treatment. There are many studies conducted globally to discuss EE on relapse of schizophrenia. A study conducted by Ng et al. on EE and relapse of schizophrenia in Hong Kong where it was found that the relapse rate was high in high EE group than that of low EE group.
From the clinical experience, the researcher had found families experienced greater burden and stigma while staying with patient with mental illness. Thus, stigma leads to increased EE as the family members verbally abused the patient and criticize him or her and sometimes becomes hostile toward the patients. Many misconceptions are attached in the Indian culture in context to mental illness which makes the person with mental illness stigmatized, socially isolated, and deprived of their needs. Not only the patient, even the family members are the target of stigma and discrimination. There are many studies available in India with stigma and EE of mental illness. However, very few studies are conducted to assess the relationship between stigma and EE among the primary caregivers of persons with schizophrenia.
Objectives of the study
- To assess the stigma among primary caregivers of persons with schizophrenia using stigma subscale of Family Interview Schedule
- To assess the EE among primary caregivers of persons with schizophrenia using Family Attitude Scale
- To assess the relationship between stigma and EE among the primary caregivers of persons with schizophrenia.
Stigma refers to a perceived negative attitude that causes someone to devalue or think less of the whole person and is measured by stigma subscale of family interview schedule.
EE refers to a construct representing some key aspects of interpersonal relationships. It includes measurements of criticism, hostility, warmth, positive comments, and emotional over-involvement and is measured by Family Attitude Scale.
Persons with schizophrenia
Schizophrenia refers to the person diagnosed with schizophrenia as per the ICD-10 criteria.
Primary care givers
Parents or siblings or spouse or children or any other person related by blood relationship or marriage who are involved in giving care to the patient for more than 1 year.
| Materials And Methods|| |
A quantitative, nonexperimental research approach was used and the research design selected for the study was descriptive correlational research design. The study was conducted in the Out Patient Department of Lokopriyo Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH). The sample in this study consisted of the primary caregivers of persons with schizophrenia attending outpatient department of LGBRIMH as per the inclusion criteria set in the planning stage. Nonprobability purposive sampling technique was used to select the sample from the desired population. In this study, stigma subscale of Family Interview Schedule was used to assess stigma among primary caregivers of persons with schizophrenia. Interpretation of the score of this scale was done as high-stigma and low-stigma. It was a four-point standardized scale from 0 (not at all) to 3 (a lot). It consists of 14 questions which were self-reported by the primary caregivers. Stigma score above mean score of the subscale was considered to be associated with high stigma and stigma score below mean score was associated with low stigma. A “Family Attitude Scale” was used to assess EE, which was developed by David J. Kavanagh. The strength of the family attitude scale (FAS) was that it offered a very internally consisted measure that was most closely related to the hostility/criticism aspect of EE determination. It consists of 30 items. The items were scored from 0 to 4. The responses are 0 = Never, 1 = Very rarely, 2 = Some days, 3 = Most days, and 4 = Every day. The FAS had high internal consistency in all samples. Among the items, some items were positively scored. These were item no 1, 9, 12, 15, 16, 20, 21, 24, 28, and 30. High FAS score indicate high EE. Interpretation of the score of this scale was done as high EE and low EE. High FAS score (above mean score) was considered to be associated with high EE and low FAS score (below mean score) with low EE. Validity of the tools was established after consultation with five experts from the field of psychiatry. Necessary modifications were made on the basis of recommendation, suggestion of the experts. Reliability of the validated tools was measured by calculating the internal consistency of the tool by the split-half method. The reliability of stigma subscale of family interview schedule and family attitude scale was found to be 0.77 and 0.88. Data were collected after obtaining the necessary permission from the authorities and informed consent from the participants.
| Results|| |
Characteristics of Sample Subjects
Sex-wise distribution of the primary caregivers of persons with schizophrenia revealed that majority, i.e., 73.3% (n = 44) were male and 26.7% (n = 16) were female. Mean and standard deviation score of age was 37.850 ± 12.798. Most of the sample was Hindu, i.e., 90% (n = 54), followed by Muslim 8.3% (n = 5) and Christian 1.7% (n = 1). Most of the sample of the present study were living in the rural area, i.e., 56.7% (n = 34), followed by semi-urban area where 30% (n = 18) of the samples were living and only 13.3% (n = 8) of them were living in the urban area. Mean and standard deviation of monthly income of the family of the primary caregivers of persons with schizophrenia was 15,956.6 ± 13,987.5. Mean and standard deviation of the duration of stay of the primary caregivers with the patient was 21.9 ± 10.4. Mean and standard deviation of the duration of caregiving to the patient by the primary caregivers was 7.7 ± 5.
As given in [Table 1], the minimum score obtained by the sample was 0 and the maximum score was 33 on the stigma subscale. The mean score and the standard deviation was 10.83 ± 8.759.
|Table 1: Status of stigma score among the primary caregivers of persons with schizophrenia (n=60)|
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As given in [Table 2], of 60 samples, 39 samples (65%) had a stigma score <10.83 of the mean score of stigma scale and 21 samples (35%) had a stigma score >10.83 of the mean score of stigma scale.
|Table 2: Distribution of stigma among the primary caregivers of persons with schizophrenia (n=60)|
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As given in [Table 3], the minimum score obtained by the sample was 0 and the maximum score was 76 on the family attitude scale. The mean score and the standard deviation was 29.68 ± 21.007
|Table 3: Range, mean, and standard deviation of expressed emotion score among the primary caregivers of persons with schizophrenia (n=60)|
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As given in [Table 4], of 60 subjects, 39 (66.7%) had a EE score <29.68 of mean score of family attitude scale and 21 (33.3%) had a EE score >29.68 of mean score of family attitude scale.
|Table 4: Distribution of expressed emotion among the primary caregivers of persons with schizophrenia (n=60)|
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As depicted in [Table 5], the correlation of stigma and EE among the primary caregivers of persons with schizophrenia, the calculated value of Pearson correlation coefficient between stigma and EE was 0.587** which is higher than the tabulated value at 0.01 level of significance. It can be interpreted that there is a significant positive correlation between stigma and EE among the primary caregivers of persons with schizophrenia.
|Table 5: Correlation of stigma and expressed emotion among the primary caregivers of persons with schizophrenia (n=60)|
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| Discussion|| |
The finding of the study showed that the majority of the primary caregivers have low stigma having a patient with psychiatric illness in their family. The present study finding was supported by another study conducted in India by Yannawar et al. where the study result showed that 33.3% of the caregivers from rural areas expressed low stigma, 66.7% of caregivers expressed medium stigma and no caregivers expressed high stigma. Alternately, 56.1% of the caregivers from urban areas expressed low stigma, 41.5% caregivers expressed medium stigma and only 2.4% of the caregivers expressed high stigma. However, the present study finding was in contrast with other study findings. A study done by Shibre et al. in Ethiopia showed that 75% of the respondents perceived that they were stigmatized or had experienced some sort of stigma due to the presence of mental illness in the family, 42% was worried about being treated differently and 37% wanted to conceal the fact that a relative was ill. The illness was attributed to supernatural forces by 27% and praying was suggested as a preferred method to deal with the problem by 65%. The reason for low stigma in the region may be because of public awareness about the concept of mental illness and its treatment, which makes the family members more understanding of the patient's mental condition. Moreover, India is a country where people are more concerned about their family members and emotional bonding is more in Indian society. Hence, the presence of such attitude and knowledge among the people keeps them away from stigma-related barrier and by breaking the resistance of stigma people moves out for the treatment of the illness. Public are more aware of the factors that originate stigma and importance of psychoeducation on concept and misconception of mental illness and its treatment which can play a significant role in combating stigma. This is supported by the study conducted by Shrivastava et al. on objective assessment of stigma by families. Several measures are mentioned by the family members to fight stigma. About 99.7% of the family members mentioned about the importance of awareness of the mental illness, 80.7% mentioned education and involvement of people mentioned by 60.5% of families. These measures are combatants of stigma.
Study finding also showed that the majority of the primary caregivers have low EE toward a family member having schizophrenia. This finding is supported by a study conducted by Azhar and Varma in Kelantan where the study result found that majority of the families (72.3%) had low EE, whereas only 25.3% had high EE and only 2.4% families were equivocal in this respect.
Moreover, during data collection, most of the primary caregivers of persons with schizophrenia expressed that their relatives were totally symptom-free and they were leading normal life along with the family members. As a result, the family dynamic is not disrupted, and the relatives' quality of life is not deteriorated because of the nonexistence of burden for taking care of them as verbalized by most of the primary caregivers. On further clarifying, it was found out the patients were on regular follow-up and are compliant with prescribed medicine, which reduces their clinical symptoms. In addition to it, it was also found during data collection that most of the primary caregivers were aware of the patients' illness and the importance of medication adherence and regular follow-up.
The Pearson correlation coefficient formula was used to find out the correlation between stigma and EE among the primary caregivers of persons with schizophrenia. The calculated value was found to be 0.587, which was higher than the tabulated value at 0.01 level of significance. It interpreted that there was a positive correlation between stigma and EE among the primary caregivers of persons with schizophrenia at a statistically significant level, i.e., if stigma increases among the primary caregivers, EE also increases toward the persons with schizophrenia by the primary caregivers.
The researcher has own experience of people with mental illness suffering more from high EE by the family members in the form of hostility and critical comments. Many of the caregivers verbalize that among various factors stigma is one of the variables which contributes to EE. As the family members expresses that the symptomatic patient creates nuisance in the family by beating, abusing family members and as well as people in the surrounding and also shows various abnormal behavior by putting off clothes in front of public and doing various abnormal gestures which are the chief complaint of almost all the family members accompanying the patient in LGBRIMH. Because of the presence of clinical features of the patient other far relatives of the patient and community people creates a barrier named stigma by not supporting the patient and family members socially, making critical comments, and creating a distance from the family. Ultimately, all these factors lead to negative EE toward the patient.
| Conclusion|| |
The present study was conducted to assess the relationship between stigma and EE among the primary caregivers of persons with schizophrenia. The finding of the study showed that the majority of the primary caregivers have low stigma and low EE having a patient with psychiatric illness in their family. However, it was found that there was a significant positive relationship between stigma and EE among the primary caregivers of persons with schizophrenia. Most of the people in Assam have adequate knowledge of mental illness which helps them to break the barrier of stigma and support the patient to access the treatment which promotes the patient's illness and create a positive motivational climate within the family.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hootman J, Houck GM, King MC. Increased mental health needs and new roles in school communities. J Child Adolesc Psychiatr Nurs 2003;16:93-101.
Pawar AA, Peters A, Rathod J. Stigma of mental illness: A study in the Indian armed forces. Med J Armed Forces India 2014;70:354-9.
Kuipers E, Watson P, Onwumere J, Bebbington P, Dunn G, Weinman J, et al.
Discrepant illness perceptions, affect and expressed emotion in people with psychosis and their carers. Soc Psychiatry Psychiatr Epidemiol 2007;42:277-83.
Tantawy E, Ashraf M, Yasser M, Yahya A, Saber A, Youssef MU. Stigma and EE: a study of people with severe psychiatric illnesses and their family members. Middle East Current Psychiatry 2014; 21:205-11. Available From: http://journals.lww.com/mecpsychiatry/Abstract/2014/10000/Stigmaandexpressedemotionsastudyofpeople. 8.aspx. [Last accessed on 2015 Dec 24].
Shibre T, Negash A, Kullgren G, Kebede D, Alem A, Fekadu A, et al.
Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Soc Psychiatry Psychiatr Epidemiol 2001;36:299-303.
Azhar MZ, Varma SL. Relationship of expressed emotion with relapse of schizophrenia patients in Kelantan. Singapore Med J 1996;37:82-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]