Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231
DOI 10.1007/s00127-016-1221-8
ORIGINAL PAPER
Self-stigma and affiliate stigma in first-episode psychosis patients
and their caregivers
Emily S. M. Chen1 • Wing Chung Chang1,2 • Christy L. M. Hui1 • Sherry K. W. Chan1
Edwin Ho Ming Lee1 • Eric Y. H. Chen1,2
Received: 24 September 2015 / Accepted: 16 April 2016 / Published online: 27 April 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Stigma is a major factor causing delayed help-
seeking and poor treatment adherence in patients with
psychotic disorders. Previous research has mostly focused
on chronic samples and the impact of culturally-relevant
variables on both patients’ and their caregivers’ stigmati-
zation is understudied. This study aimed to examine the
relationships between various forms of stigma, ‘‘face con-
cern’’, and clinical characteristics in a group of Chinese
first-episode psychosis (FEP) patients and their caregivers.
Methods Forty-four Hong Kong Chinese aged 15–54 years
presenting with FEP to psychiatric services and their
caregivers were recruited. Assessments on self-stigma,
affiliate stigma, perceived public stigma, ‘‘face concern’’,
symptom severity and subjective quality of life (QoL) were
conducted.
Results Self-stigma of FEP patients was correlated with
perceived public stigma, ‘‘face concern’’, insight and psy-
chological health of QoL. Multiple regression analysis
revealed that perceived public stigma and ‘‘face concern’’
independently predicted self-stigma. Mediation analysis
further suggested that ‘‘face concern’’ partially mediated
the relationship between perceived public stigma and self-
stigma. Caregivers’ affiliate stigma was significantly
associated with higher levels of stress, and symptoms of
depression and anxiety. Affiliate stigma did not correlate
with perceived public stigma and ‘‘face concern’’.
& Wing Chung Chang
changwc@hku.hk
1
Department of Psychiatry, The University of Hong Kong,
Queen Mary Hospital, Pokfulam, Hong Kong
2
The State Key Laboratory of Brain and Cognitive Sciences,
The University of Hong Kong, Pokfulam, Hong Kong
•
Conclusion Our results indicate a critical role of perceived
public stigma and fear of losing face in determining self-
stigma in Chinese patients with FEP. Caregivers with
greater degree of affiliate stigma experience increased
stress and emotional distress. Our findings highlight the
importance to examine culturally specific factors that may
contribute to the development of self-stigma in first-epi-
sode populations of different ethnicities.
Keywords Face concern
Perceived public stigma

Caregivers’ distress
Self-stigma
Affiliate stigma
Introduction
Stigma has been identified as one of the major causes for
delayed helping-seeking and poor treatment adherence in
patients with psychotic disorders. Stigmatization involves
‘‘elements of labeling, stereotyping, separation, status loss,
and discrimination co-occur in a power situation that
allows them to unfold’’ [1]. In general, stigma can be
further classified into three distinct domains, namely public
stigma, self-stigma and affiliate stigma. Public stigma
represents the endorsement of related stereotypes and
prejudice as well as the manifestation of discrimination
from general public [2]. Self-stigma is generated when
individuals with mental illness internalize perceived public
stigma. This in turn results in diminished self-esteem and
self-efficacy [3], and also affects patients’ family members
who may then develop affiliate stigma [4, 5], which refers
to the caregivers’ internalized public stigma towards
patients [6].
Literature consistently indicates that self-stigma may
impede the recovery process of patients with psychotic
disorders [7–9]. Previous studies have revealed that better
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insight, depression, lower self-esteem, poorer functioning
and quality of life (QoL), and greater positive symptom
severity are associated with self-stigma in schizophrenia
patients [10–17]. Alternatively, it is suggested that
schizophrenia patients may internalize prejudices from
public towards them even when they did not experience
actual discrimination [18]. Patients’ perceived public
stigma may thus constitute an important factor predicting
the development of self-stigma.
Of note, accumulating evidence has suggested that
stigmatization towards mental illness, in particular psy-
chotic disorders, is worse in Asian populations (including
Chinese) than Western counterparts [19–21]. One plausible
explanation of heightened stigmatization in Chinese pop-
ulations might be an emphasis on ‘‘face concern’’ in the
context of Chinese collectivistic culture. Briefly, ‘‘face
concern’’ refers to an individual’s concern about preserving
and maintaining social image of oneself and avoid losing
face [22]. ‘‘Loss of face’’ represents one’s failure to fulfill
the essential requirements with respect to one’s social
position [23], which will be perceived as incompetence and
results in losing trust, social isolation, and a sense of
shame. Individuals with psychotic disorders may tend to
conceal their illness to avoid losing face and attaching
disgrace to their families. In parallel, one recent local study
[24] showed that more than half of the family members and
spouse of schizophrenia patients wished to conceal
patient’s illness from others, and 41.1 % of them perceived
being treated unfairly owing to patient’s illness. Recent
data also suggest that ‘‘face concern’’ is related to emo-
tional distress and affiliate stigma in caregivers of patients
with mental illness or intellectual disabilities [25, 26].
Although there is evidence demonstrating that ‘‘face con-
cern’’ is related to self-stigma in individuals with certain
medical conditions [27], no research has been conducted to
examine the role of ‘‘face concern’’ in contributing to self-
stigma and affiliate stigma associated with psychotic
disorders.
Thus far, previous studies on self-stigma in
schizophrenia have mainly focused on its relationship with
clinical variables and recruited patients with chronic ill-
ness. Predictive factors of self-stigma in the early stage of
psychotic disorders, particularly in first-episode psychosis
(FEP) samples, are under-studied. This is of potentially
significant implication as self-stigma emerging in the initial
years of illness would likely be more amenable to psy-
chosocial intervention. In addition, affiliate stigma of
caregivers with family members suffering from FEP has
not been systematically investigated. Few attempts have
been made to provide a comprehensive account of cultural
elements in the development of self-stigma, including
‘‘face concern’’ [18] in FEP patients. In the current study,
we examined a representative cohort of Chinese FEP
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Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231
patients and their caregivers in Hong Kong (HK) with an
aim to (1) identify factors associated with self-stigma and
affiliate stigma; and to (2) examine a potential pathway
underlying the formation of self-stigma based on those
identified predictive variables.
Method
Participants and setting
Patients aged between 15 and 54 years presenting with FEP
to the psychiatric outpatient unit in Hong Kong Island
catchment area, and their caregivers were recruited
between July 2005 and December 2008. Patients with
learning disabilities, drug-induced psychosis or psychosis
due to general medical condition were excluded. The study
was approved by the local institutional review boards and
all participants gave written informed consent before
participation.
Assessments and procedure
Clinical assessments
Patient’s diagnosis was ascertained by senior research
psychiatrist using the Chinese-Bilingual Structured Clin-
ical Interview for DSM-IV Axis I Disorders, Patient
Edition (CB-SCID-I/P) [28], which has been shown to
yield reliable DSM-IV diagnoses in Chinese patients with
psychotic disorders [28]. The interview for the retro-
spective assessment of the onset of schizophrenia
(IRAOS) [29] was used to confirm the first-episode status
and to measure the duration of untreated psychosis (DUP),
which is the time interval between the onset of positive
symptoms and antipsychotic treatment initiation. Psy-
chopathology was measured using the positive and neg-
ative syndrome scale (PANSS) [30]. The intra-class
correlation coefficients (ICC) for total PANSS score,
positive symptom and negative symptom subscales were
0.83, 0.84 and 0.73, respectively. Depressive symptom
severity was assessed by the calgary depression scale for
schizophrenia (CDSS) [31]. Insight was measured by the
first three items (i.e., general items) of the Scale to Assess
Unawareness of Mental Disorder (SUMD) [32]. Study
assessments were administered by research assistants who
were supervised by senior research psychiatrists. Training
on the use of assessments was provided to research
assistants prior to participant recruitment. Regular meet-
ings were held throughout the study period to ensure strict
adherence to assessment manual and to resolve any
ambiguity in clinical information during the data collec-
tion process.
Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231
Stigma assessments
Self-stigma
Self-stigma scale-short version [33] was used to measure
internalization of stigma in FEP patients. It is a 9-item self-
rated questionnaire covering affective, cognitive, and
behavioral components. In this study, mean score was
computed (the higher the mean score, the greater the
degree of self-stigma). This scale was validated in Chinese
patients with severe mental illness including schizophrenia
and was shown to have high convergent validity in relation
to the key constructs that are closely associated with self-
stigma [33].
Perceived public stigma
The Stigma and Acceptance Scale [34] was used to mea-
sure patients’ and their caregivers’ perceived public stigma
towards psychotic disorders. This scale comprises two
subscales which measure stigma and acceptance toward
mental illness, respectively. In this study, we only applied
the 12-item stigma subscale. Good reliability of this scale
was demonstrated in a previous study examining Chinese
general population in HK [34]. The mean score was cal-
culated, with the higher score indicating higher level of
perceived public stigma.
Affiliate stigma
The 22-item Affiliate Stigma Scale [6] was used to
measure the internalization of stigma in caregivers. It
consists of affective, cognitive, and behavioral domains.
The mean score was used for subsequent analysis (higher
score indicating higher level of affiliate stigma). This
scale has been validated and studied in caregivers of
individuals with mental illness or intellectual disabilities
[6].
Psychological variables
Face concern
‘‘Face concern’’ was measured using the Loss of Face
Scale [35]. It consists of 21 items which assess concerns
about social norm violations or expectations that incur a
loss of face to the self and to others. Participants (both
patients and caregivers) rated each item on a Likert-scale
of 1 (strongly disagree) to 7 (strongly agree). Mean score
was computed, with higher score indicating greater con-
cern of losing face. This scale has been validated among
Chinese populations with good validity and reliability
[36].
1227
Subjective quality of life
Subjective QoL of FEP patients was measured using the
World Health Organization Quality of Life Scale, abbre-
viated HK version (WHOQOL-BREF(HK)), which has
been validated in HK Chinese population [37], and has
previously been studied in FEP patients [38]. This is a
26-item, self-administered questionnaire covering domains
of physical health, psychological health, social relationship
and environmental factors. Each item is scored on a 5-point
scale with higher scores indicating better QoL. In this
study, the mean total score of each domain was computed
for analysis.
Mood states of caregivers
Depression Anxiety Stress Scale—Chinese version was
used to measure caregivers’ levels of depression, anxiety
and stress over the past 1 week [39]. It is a self-adminis-
tered scale with 42 items, scored on three-point scale. The
total score of each of the three mood states was derived,
with higher score indicating more severe in the related
mood states.
Statistical analyses
Correlation analyses were conducted to examine the rela-
tionships of self-stigma with perceived public stigma, and
clinical and psychological variables. Those variables that
were significantly correlated with self-stigma were then
included in a multiple regression analysis to determine
which factors independently predicted self-stigma. In
addition, we followed Baron and Kenny’s four-step pro-
cedure [40] to test the mediation effects of those identified
predictors on the development of self-stigma. Relationships
of affiliate stigma with other stigma measures, as well as
clinical and psychological variables were also examined by
correlation analyses. DUP was log-transformed due to its
highly skewed distribution. All analyses were two-tailed
and the level of significance was set at p \ 0.05.
Results
Characteristics of the sample
Forty-four pairs of FEP patients and their caregivers were
studied. The mean age, years of education and DUP of
patients are 25.8 years (SD = 9.7), 11.5 years (SD = 2.9),
and 292.4 days (SD = 949.2, median = 75), respectively.
The majority of patients was diagnosed to have
schizophrenia (77.3 %, n = 34), followed by brief psy-
chotic disorder (11.4 %, n = 5), psychosis not otherwise
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1228 Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231

Table 1 Demographic and clinical characteristics of first-episode Table 2 Correlations of self-stigma with clinical and psychological
psychosis patients variables
Demographics Variable r p

Age, years, mean (SD) 25.82 (9.74) Clinical characteristics

Education attained, years, mean (SD) 11.52 (2.88) PANSS positive symptoms score -0.004 n.s.
Male gender, n (%) 23 (52.3) PANSS negative symptoms score -0.27 n.s.
Clinical characteristics PANSS general psychopathology score -0.18 n.s.
DUP, days, mean (SD) 292.42 (949.21) CDSS total score -0.05 n.s.
Diagnosis, n (%) SUMD score -0.35 0.02
a
Schizophrenia-spectrum disorder 35 (79.55) Log DUP 0.15 n.s.
Other non-affective psychosesb 9 (20.45) Stigma and psychological variables
Symptoms severity, mean (SD) Perceived public stigma 0.63 0.001
PANSS positive symptoms score 8.16 (2.63) Loss of face 0.56 0.001
PANSS negative symptoms score 11.64 (7.44) WHOQoL-Bref (HK)
PANSS general psychopathology score 20.11 (4.69) Physical health dimension -0.28 n.s.
CDSS total score 0.35 (0.84) Psychological health dimension -0.31 0.049
a
Schizophrenia-spectrum disorder included schizophrenia and Social relations dimension -0.15 n.s.
schizoaffective disorder Satisfaction with environment dimension -0.04 n.s.
b
Other non-affective psychoses included brief psychotic disorder Pearson-product correlation analyses were conducted
and psychosis not otherwise specified (NOS)
CDSS calgary depression scale for schizophrenia, DUP duration of
CDSS calgary depression scale for schizophrenia, DUP duration of untreated psychosis, PANSS positive and negative syndrome scale,
untreated psychosis, PANSS positive and negative syndrome scale SUMD scale to assess unawareness of mental disorder, WHOQoL-
Bref (HK) World Health Organization quality of life scale—abbre-
viated version (Hong Kong)
specified (9.1 %, n = 4), and schizoaffective disorders
(2.3 %, n = 1) (Table 1).
Relationships of affiliate stigma with stigma, clinical
Relationships of self-stigma with clinical and psychological variables
and psychological variables
As shown in Table 4, affiliate stigma was positively cor-
As shown in Table 2, insight, loss of face, and perceived related with depression, anxiety and stress dimension
public stigma were positively correlated with self-stigma, scores of the Depression Anxiety Stress Scale. There were
while psychological health dimension of QoL was inver- no correlations between affiliate stigma and measures of
sely correlated with self-stigma. Multiple regression anal- various symptom dimensions. Affiliate stigma also did not
ysis revealed that greater concern of loss of face and a correlate with self-stigma and perceived public stigma.
higher degree of perceived public stigma were indepen-
dently associated with patients’ self-stigma (Table 3).
We then tested the hypothesized mediation model based Discussion
on Baron and Kenny’s four-step procedure [40]. First, the
predictor variable (i.e., perceived public stigma) was sig- The current study systematically investigated the correlates
nificantly associated with the outcome variable (i.e., self- of self-stigma and affiliate stigma of Chinese FEP patients
stigma) (b = 0.63, p \ 0.001). Second, perceived public and their caregivers, respectively. Three major findings
stigma was significantly associated with the hypothesized emerged. First, perceived public stigma and ‘‘face con-
mediating variable (i.e., loss of face) (b = 0.37, p \ 0.05). cern’’ were found to be independently associated with
Third, loss of face was significantly associated with self- patients’ self-stigma. Second, ‘‘face concern’’ partially
stigma (b = 0.53, p \ 0.001). Finally, perceived public mediated the relationship between perceived public stigma
stigma was significantly associated with self-stigma but and self-stigma. Third, affiliate stigma of caregivers was
with reduced effect (b = 0.50, p \ 0.001) when loss of related to higher levels of stress, depression and anxiety.
face was controlled for. Sobel test showed a near signifi- Consistent with previous research [10, 11, 18, 33, 41],
cant result (z = 1.93, p = 0.05), suggesting that ‘‘face we found that self-stigma was correlated with perceived
concern’’ partially mediated the relationship between per- public stigma, ‘‘face concern’’, insight and psychological
ceived public stigma and self-stigma. health of QoL. Our results of multiple regression analysis

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Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231 1229

Table 3 Multiple regression

Variables Adjusted OR 95 % CI t p
analysis for predictors of self-
stigma Perceived public stigma 0.474 0.22 to 0.72 3.81 0.001
Loss of face 0.317 0.05 to 0.55 2.40 0.022
SUMD score -0.120 -0.49 to 2.82 -0.94 n.s.
WHOQoL-Bref (HK) psychological health -0.114 -0.40 to 0.14 -0.95 n.s.
SUMD scale to assess unawareness of mental disorder, WHOQoL-Bref (HK) World Health Organization
quality of life scale—abbreviated version (Hong Kong)

Table 4 Correlations of affiliate stigma with patients’ clinical vari-
ables and caregivers’ psychological measures
Variables r p
Patients’ clinical and stigma measures
PANSS positive symptoms score 0.05
PANSS negative symptoms score 0.16
PANSS general psychopathology score -0.16
CDSS total score -0.22
Self-stigma scale score -0.12
Caregivers’ stigma and psychological measures
Perceived public stigma score 0.10
Loss of face, mean total score 0.20
Depression anxiety stress scale
Depression subscale score 0.40
Anxiety subscale score 0.39
Stress subscale score 0.33
Pearson-product correlation analyses were conducted
CDSS calgary depression scale for depression, PANSS positive and
negative syndrome scale
provide further evidence supporting the critical role of
perceived public stigma and fear of losing face in deter-
mining the degree of self-stigma in FEP patients. The
finding that self-stigma was independently predicted by
perceived public stigma is in parallel with Link’s modified
labeling theory [1, 42], whereby negative public attitudes
and cultural stereotypes attached to psychosis are absorbed
and internalized during a person’s early life stages, and
these conceptions as well as the expectation that patients
with psychosis will be devalued and discriminated against
will then become personally relevant to individuals who
are diagnosed with psychotic disorder. This may in turn
significantly contribute to the development of self-stigma
in FEP patients. Intriguingly, ‘‘face concern’’ was shown to
play a mediating role on the relationship between perceived
public stigma and self-stigma. These findings thus concur
with the literature [38] suggesting that individuals who
have greater degree of ‘‘face concern’’ might be more
sensitive to the public attitudes and prejudices towards
mental illness, which in turn increases their propensity to
self-stigmatization. Alternatively, prior studies regarding
public perceptions on mental illness have consistently
linked patients with psychotic disorders to negative attri-
butes such as dangerousness, propensity to violence,
unpredictability and personal weakness [34, 43]. It might
be plausible that the biased attribution of psychotic
n.s. symptoms to those aforementioned undesirable traits
n.s. instead of the manifestation of a medical illness per se may
n.s. negate the applicability of a sick role to patients with
n.s. psychotic disorders who might then perceive their illness
n.s. experiences as loss of face. Although ‘‘face concern’’ is
shown to be particularly salient among Chinese community
n.s. [35, 36], it may also be a potentially useful construct in
n.s. understanding stigmatization and psychological distress in
patients of other ethnicities including Western populations.
0.008 Further research should extend the current data to exam-
0.011 ining the role of ‘‘face concern’’ on stigma experience
0.035 among culturally-diverse samples.
Conversely, our results of lack of significant correla-
tions between self-stigma and psychotic symptoms were in
line with many [15, 18, 41, 44], but not all previous studies
[11, 45, 46]. We also failed to demonstrate significant
association between depressive symptom severity and self-
stigma, which is in contrast with the findings of some prior
reports [12, 13]. One possible explanation for such dis-
crepancy might be the relatively low depressive symptom
levels of our FEP cohort. The limited variance in depres-
sive symptom rating may obscure the potentially signifi-
cant relationship between depression and self-stigma.
In agreement with previous studies [25, 26], we found
that caregivers’ affiliate stigma was significantly associated
with mood symptoms and stress level. That is, caregivers
with greater degree of affiliate stigma will experience more
severe depressive and anxiety symptoms, as well as higher
levels of stress. Our findings that affiliate stigma was not
related to perceived public stigma or ‘‘face concern’’ were
somewhat unexpected and were contrary to the results of
several past studies which revealed that there was a modest
association between ‘‘face concern’’ and affiliate stigma in
caregivers of individuals with mental illness (including
chronic schizophrenia) [25] or intellectual disabilities [26].
Our result thus suggests that the mechanisms underlying
the development of stigma might be different between FEP
patients and their caregivers. It might also be plausible that

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a longer period of time is required for the caregivers to
fully realize the potential long-term implications of psy-
chotic disorder inflicted upon their ill relatives and so do
the processes of incorporating fear of losing face and their
internalization of perceived public stigma. Alternatively,
we failed to find correlation between affiliate stigma and
self-stigma of FEP patients. This may partly be
attributable to our relatively small sample size compro-
mising the power to detect potential significant associa-
tions. However, this may also suggest relatively limited
impacts of caregivers’ attitudes to illness on self-stigmati-
zation. Owing to the scarcity of existing data, further
research is needed to elucidate both general and potentially
culture-specific factors associated with affiliate stigma.
Our results have several clinical implications. First,
given that both perceived public stigma and ‘‘face con-
cern’’ were found to predict self-stigma in our FEP cohort,
comprehensive evaluation of patients’ perceptions towards
psychosis, appraisal of stigmatizing beliefs including cul-
turally-salient stereotypes, and stigma-coping strategies
should be incorporated in early psychosis service to facil-
itate identification and provision of interventions to those
patients who are vulnerable to experience heightened self-
stigma and its associated psychological distress. Second, as
caregivers frequently encounter significant difficulties and
psychological distress when taking care of their ill relatives
with FEP [47], early detection, preemptive management
via psychoeducation, and more specific interventions such
as stigma-coping skills training and caregiver support
group to reduce affiliate stigma emerging in the initial
stage of illness may therefore help alleviate caregiver
burden and minimize their risk of developing psychiatric
morbidities. From public health perspective, although
educational interventions combined with contact experi-
ences have been showed to effectively reduce public
stigma [48, 49], programs specifically addressing the myths
and negative attributions that are relevant to the local
ethno-cultural contexts should also be incorporated for
stigma mitigation [34, 50]. In longer term, this will facil-
itate reducing perceived public stigma and fear of losing
face in relation to psychosis, and thereby improving self-
stigma of FEP patients.
This study has several merits that deserved attention.
First, studying a representative cohort of first-episode
patient-caregiver pairs enables us to investigate the inter-
relationships between various domains of stigma, i.e., self-
stigma, perceived public stigma and affiliate stigma,
attached to the diagnosis of FEP. Second, this is one of the
first few studies that take into consideration the culturally-
relevant factors (i.e., ‘‘face concern’’) in examining stigma
in the early course of psychotic illness. Several method-
ological limitations, however, warrant consideration in
interpreting the study results. First, the sample size was
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Soc Psychiatry Psychiatr Epidemiol (2016) 51:1225–1231
modest which may compromise the statistical power to
detect subtle but potentially significant associations. Sec-
ond, several variables including illness appraisal and cop-
ing strategies, which may also be related to self-stigma and
affiliate stigma, were not assessed in this study. Third, the
cross-sectional nature of this study precludes us from
drawing any direct causality among various studied vari-
ables. Prospective follow-up research is thus required to
clarify the evolution and longitudinal relationships between
different stigma constructs and related factors in the early
course of psychotic illness.
Acknowledgments The authors would like to thank all coordinating
clinicians and staff from the participating hospitals, clinics and
medical records departments for their kind assistance.
Compliance with ethical standards
Conflict of interest E.Y.H.C. has participated in the paid advisory
board for Otsuka, has received educational grant support from Jans-
sen-Cilag, and has received research funding from Astra-Zeneca,
Janssen-Cilag, Eli Lilly, Sanofi-Aventis and Otsuka. The authors
report no conflicts of interest. The authors alone are responsible for
the content and writing of the paper.
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