Despite reporting levels of weight-based stigmatization that are lower than published levels for non-psychiatric groups, our study group comprised of persons with severe mental illness (i.e., schizophrenia or schizoaffective disorders) reported negative weight-based self-bias at to the same extent as reported by a non-psychiatric sample. This suggests that there is significant self-reflection on the personal implications of weight among these individuals with levels of highly negative self-attitudes on par with the general population. Furthermore, weight-based self-bias was significantly related to poorer quality of life (and accounted for an additional 11% of the variance) even after controlling for demographic factors and levels of negative affect. Although our sample was significantly more obese than the Durso and Latner community comparison sample, this is not likely to account for our findings here because neither we nor Durso and Latner found a relationship between actual weight status and weight-based self-bias. Similarly, we found that actual weight status was not significantly correlated with perceptions of stigma or negative affect. As has been observed with non-psychiatric groups (Weiden, Mackell, & McDonnell, 2004
), subjective perceptions of weight status are more related to distress than actual weight among individuals with schizophrenia. In fact, this is consistent with research on schizophrenia-related self-stigma, which was found to be more predictive of psychiatric hospitalization among a sample of individuals with schizophrenia than the level of actual discrimination (Franz et al., 2010
). These findings highlight the specific and unique negative burden of weight-related self-bias even among persons with severe mental illness such as schizophrenia.
Our patients with serious psychiatric illness reported lower levels of stigmatization by others than reported by non-psychiatric samples (Durso & Latner, 2008
; Puhl & Brownell, 2006
). The reason for this finding is unclear and should be the focus of future research. We can speculate that perhaps our participants might be unable to differentiate between stigma experiences due to their weight versus stigma experiences due to their mental illness. Gender significantly impacted the relationship between stigmatization by others and negative affect. For women, but not men, more experiences of stigma by others was related to higher levels of negative affect and was related to more self-bias. This may be linked to an increased salience to stigmatization by others or perhaps a higher degree of sensitivity to others’ weight-based attitudes for women (versus men) with schizophrenia. Differentially negative social attitudes toward obese women versus obese men may account for the difference observed here (Chen & Brown, 2005
; Azarbad & Gonder-Frederick, 2010
). It is also possible that for men with schizophrenia, other forms of stigma may be more salient and more related to mood, such as stigma due to mental illness.
In contrast to the findings regarding stigmatization by others, self-directed weight-bias was associated with negative affect and quality of life for both males and females. This finding is consistent with previous research with non-psychiatric populations (Durso & Latner, 2008
). Although this study was correlational which precludes any causal conclusions, we can speculate that self-directed weight-bias could contribute to negative affect and poorer quality of life given findings reported for other obese patient groups (Chen et al., 2007
). However, negative affect could lead to a negative attitude toward the self, which could foster more negative attitudes toward one's weight and one’s perceptions of quality of life. We note, however, that self-directed weight-bias was still significantly related to poorer quality of life even after controlling for negative affect.
We did not observe a relationship between our physical and clinical measures and attitudes toward medication. In contrast to previous studies (Parsons et al., 2009
; Switaj et al., 2009
), it appears that weight gain likely attributable to antipsychotic medications in this patient group did not impact perceptions of their medication treatment. The reasons for this apparent discrepancy are unknown and warrant further study. It is possible that participants were not comfortable reporting medication non-adherence to study staff or self-presentation bias may have interfered with the validity of the measure in this study (Byerly et al., 2007
). Further research will be needed to determine if there is a link between weight-based stigma, self-bias, medication adherence, and quality of life.
Several limitations should be noted. We assessed individuals with schizophrenia and schizoaffective disorder seeking treatment at one university-affiliated community mental health center in the northern eastern United States and our findings may not generalize to other persons with schizophrenia. It is possible, for example, that there may exist regional or geographic differences or that such views may differ across different clinical settings. Although we assessed general self-reported negative affect, we did not assess subjective distress directly attributable to weight, which could be an influencing factor in the relationship between stigma, self-directed weight-bias, mood, and medication compliance. However, given the fact that our study group consisted of individuals seeking treatment for weight-loss, it can be reasonably assumed that they experienced negative affect due to their weight; anecdotally, many participants discussed their distress over their weight with study staff. The fact that these individuals were self-selected for a weight loss program may in fact be an indication that they are more concerned about their weight than a typical group of individuals with schizophrenia/schizoaffective disorder, potentially further limiting generalizability. Finally, this cross-sectional study was correlational in nature and therefore precludes any causal conclusions. Future studies should examine the nature and significance of such negative weight-based experiences and attitudes longitudinally and in relation to both illness course and treatment experiences.
Despite reporting levels of weight-based stigmatization that are lower than published levels for non-psychiatric groups, individuals with schizophrenia and schizoaffective disorders reported negative weight-based self-bias on par with non-psychiatric community comparison sample. Weight-related self-bias is associated with poorer quality of life even after controlling for negative affect. Therefore it is critically important that clinicians who work with individuals with severe mental illness be sensitive to these issues and recognize that that the negative impact of excess weight is not limited to physical health. These individuals may also suffer from both being the targets of anti-obesity attitudes as well as having internalized such negative attitudes towards themselves and therefore clinicians should work to address these issues to help ensure the most optimal outcomes for their clients.