ارتباط مقاومت داغ ننگ با تنظیم احساسات: تصویربرداری رزونانس مغناطیسی عملکردی و یافته های نوروفیزیولوژیک

Backgroud Personal characteristics contribute to whether negative attitudes in society are internalized as deteriorating self-stigma. Studies in healthy subjects suggest that resilience is associated with the regulation of amygdala activation by the medial prefrontal cortex (mPFC), but little is known about the factors that contribute to individual stigma resistance in psychiatric patients. Methods We assessed stigma (by measuring association strengths between social inferiority and schizophrenia by an implicit association test) in 20 patients with schizophrenia and in 16 age- and sex-matched healthy control subjects. The brain activation strengths were measured by functional magnetic resonance imaging during evaluation of schizophrenia-related statements and of control statements. Results Association strengths between social inferiority and schizophrenia were inversely related to the strength of the activation of the rostro-ventral mPFC. This inverse correlation survived adjustment for global functioning, depression symptom scores, and insight. Activation of the rostro-ventral mPFC was negatively correlated with activation of the amygdala. The association strengths between social inferiority and schizophrenia correlated with the compromised performance in a Stroop task, which is a measure of cognitive regulation. Discussion Our findings suggest that individual stigma resistance is associated with emotion regulation. These findings may help to understand better stigma resistance and thereby aid the development of patient interventions that add to the public anti-stigma work in reducing devastating effects of stigma.

Persons with mental disorders are doubly affected by their condition. First, the symptoms of the illness cause distress and impairment. Second, social misconceptions about mental disorders burden the patient with the stigma of “insanity”. Cultural practices of naming persons with a mental disorder, say schizophrenics, exacerbate the process of stigmatization by separating “us” from “them”. Most of these patients silently accept the negative culturally held attitudes. Social discrimination and rejection are related to a subjective fear of being stigmatized and also to self-stigmatization. The latter is an acceptance of social negative appraisals as true evaluation of one's value as a human being [1]. Self-stigmatization leads to the loss of self-esteem [2], a decrease of the quality of life, and to depression [3] and [4]. Such internalized stigma may be one reason why the reduction of objective symptoms of psychosis is not sufficient in itself in improving the subjective quality of life in people with mental disorders. More fundamentally, the importance of self-stigmatization reflects a pervasive shift of priorities in health systems, health care ethics and even health economics towards outcomes subjectively valued by patients. These subjective outcomes include autonomy, quality of life and patient-reported outcomes in general [5] and [6]. Not all people with mental illness are uniformally susceptible to self-stigmatization. Some seem to be able to resist negative attitudes. Such stigma resistance interferes with aquiescence in applying negative attitudes that, in turn, increase the subjective influence of stigma and impairs recovery. Therefore, enhancing stigma resistance could become an important target of treatment interventions. Enhancement of stigma resistance comprises one of the core aspects of recovery-orientation movement: “the development of new meaning and purpose in one's life, irrespective of the presence or absence of symptoms of mental illness” [7]. Self-stigma has usually been measured by explicit interviews or questionnaires [8]. However, respondents may have varying self-representational strategies or may be unaware of their automatic appraisals [9], and for sensitive issues the explicit scales may be biased towards emotionally neutral answers [10]. Implicit measures may have better predictive validity than explicit measures in sensitive areas such as intergroup or interracial behavior [10] and [11]. Therefore, researchers have started to use implicit association tests to measure implicit association strengths between mental disorders and stigma [9] and [12]. Consequently, we measured implicit association strengths between schizophrenia and social inferiority in this study. Although the neurobiological underpinnings of resilience towards mental disorders have attracted recent interest [13] and [14], the neurobiology of stigma resistance remains unknown. It is known that in healthy subjects, the function of the medial prefrontal cortex (mPFC) is related to reappraisals and optimism, and that the functioning of that same brain region is attenuated under conditions of anxiety and depression [13]. The rostro-ventral mPFC has been especially associated with emotion regulation [15] and control of the amygdala, which are factors that may play important roles in resilience [13] and [14]. We therefore hypothesized that the activity of the rostro-ventral mPFC during the processing of one's illness is associated with a weaker amygdala activation and weaker implicit associations between schizophrenia and social inferiority in subjects with schizophrenia.