Attitudes Towards Mental Health Conditions

Abstract

The stigmatisations attached to mental illnesses can have a catastrophic effect on the lives of these people who are given a psychiatric diagnosis. Many theorists have endeavoured to reduce the attached social stigmatisations associated with schizophrenia and other severe mental illness conditions, through the idea of renaming schizophrenia. The purpose of the current study aims to assess whether using the alterative mental health diagnosis label ‘salience syndrome’ than ‘schizophrenia’ present more positive community attitudes also lessening desire for social distance and whether or not familiarity with the diagnosis minimises such perceived stigmatisation and social distance towards individuals with a schizophrenia diagnosis. A total of ninety nine participants participated in an online study based on a volunteer sample of the general population. Two between-subjects two-way ANOVA’s found that neither factors measured; mental health diagnosis label (Schizophrenia/Salience syndrome) and level of familiarity (minimal/moderate/in-depth) played no role in reducing community attitude or social distance scores. The findings obtained from the present study indicate that the possibility of renaming schizophrenia in attempts to reduce stigma amongst the general population is still questionable and yet to be established with sufficient supporting literature.

Introduction

Mental illness generally refers to conditions that can cause mild to severe disturbances of an individual’s thought, emotion and/or behaviour (Manderscheid et al, 2010). Such alterations of a person’s cognitive mechanisms can have a dramatic impact on people’s ability to cope with life’s ordinary functionality; the amalgamation of the associated distress and disability caused by a mental illness can have a catastrophic effect on the lives of these people who have a psychiatric diagnosis (Brohan, Slade, Clement & Thornicroft, 2010).

The commonality of experiencing some form of mental health condition has become increasingly widespread amongst the general population; in the United Kingdom alone, approximately 1 in 6 individuals will need some method of treatment for their mental ill health during their lifetime (Office for National Statistics, 2017).

Statistically schizophrenia is not the most predominant mental health condition worldwide; however, this form of psychological disorder is acknowledge for affecting roughly 1% of the general population (NICE, 2009). Schizophrenia is characterised by a combination of both positive and negative symptoms including: delusional thinking, hallucinations, disorganised speech, peculiar behaviour characteristics and catatonia (American Psychiatric Association, 2013). The diagnostic and statistical manual of mental disorders (DSM-IV) states that in order for diagnosis, some symptoms must be persistent for at least 6 months, with the inclusion of active symptoms during a period of 1 month (American Psychiatric Association, 2013); with the assumption that an individual’s symptoms should be distinguished by the definable psychiatric boundaries of diagnostic criteria and that those groups of individuals who are congruent with a certain mental health condition are relatively homogeneous (American Psychiatric Association, 2000). Ultimately a range of symptoms this psychologically invasive can cease individuals experiencing reality like most.

Stigmatisation and attitudes towards mental health
The vast prevalence of mental illness means that many individuals have to face the demanding challenges allied with a mental health diagnosis. Likewise countless individuals also have to endeavour the attached social stigmatisations associated with mental illnesses which are held by the remaining general population. Public stigma refers to a phenomenon that involves factors of negative attitudes, stereotypes, prejudice outlook, and discriminatory reactions against a particular person or group (Bagley & King, 2005). The past few decades have witnessed continuity and change in our understanding of the public stigma associated with mental illness; within literature there has been a noticeable trend of commonly held stereotypes about people with mental illness such as: dangerousness, that those with a mental illness are potentially violence in nature and incompetence, that those with a mental illness are incapable of living independently or can hold down a job all of which have been consistently identified across various surveys (Hamre et al, 1994; Link et al, 1999; Corrigan, 2000). Van Dorn et al, (2005) suggested that the reason for such negative attitudes towards schizophrenia is often associated with the perception that people with schizophrenia are unpredictable and dangerous. Van Dorn et al, (2005) measured the perceived likelihood of violence of a hypothetical person diagnosed with schizophrenia where it was concluded that there was in fact an association between personal beliefs about the likelihood of violence of a person diagnosed of schizophrenia and desire for social distance. There has been various initiatives and schemes designed to reduce such stigmatising views within the realm of mental health. In the United Kingdom the national programme for reducing stigma is called ‘Time To Change’ which is delivered by two mental health support charities: Mind and Rethink Mental illness. Since then in 2016 the effectiveness of this long term programme was investigated for the year 2009-2015; Henderson et al (2016) examining whether there were any improvements in attitudes, social distance and mental health knowledge within the general population. Henderson et al (2016) found that the ‘Time To Change’ programme was effective in reducing overall stigma as the results indicated an improvement within each of the domains examined. Nonetheless, research still persists with the hopes of finding alternative ways to excel in reducing stigma.

Mental health diagnosis labels
Mental health diagnosis labels are diagnostic classifications individuals obtain when they are diagnosed with a mental illness; it is such labels that often serve as cues to signal stereotypes and stigmatizations. With the understanding that such labels cause stigmatisation manifestations; ongoing debates about renaming schizophrenia have predominately been conducted in Asian countries with Japan to be the first to officially change the diagnosis label to ‘integration disorder’. Since then there has been advances into other potential alternative diagnostic labels to replace schizophrenia.  Van Os (2009) states that the concept of ‘salience’ as a renaming effort has the potential to reduce societal stigmatisations and encourage the awareness amongst the general population to recognise psychosis as a universal normality within the context of human behaviour. The outlook that renaming schizophrenia to alternatives such as ‘salience syndrome’ on Van Os (2009) account would encourage the view that psychosis is a normal constituent of human behaviour due to the descriptive nature of the term in conjunction with the level of understanding of the term ‘salience’. Likewise Barkus (2014) states that the term ‘salience’ through the eyes of someone diagnosed with schizophrenia, relates to capability a stimuli has the attention of those experiencing schizophrenia which then leads to driving their behaviour in response. In other words; the term ‘salience’ endorses that to a schizophrenic, a stimuli can posses extra significance which ultimately influences the symptomatic behaviours of schizophrenia which stand out against the remaining general population. Advances in research since then in the UK have deliberated the question, what to replace the diagnosis name to? (Bentall, 2013).  In recent research Ellison et al, (2015) conducted a study focusing on the effects of different names for the diagnosis schizophrenia. Participants were issued two vignettes meeting DSM-IV and ICD-10 criteria and were either labelled schizophrenia or integration disorder; followed by questionnaires assessing five different aspects of public stigma (causal beliefs, prognosis, emotional reactions, stereotypes and social distance) after each vignette. It was found the label ‘integration disorder’ composed mixed results; compared to the diagnosis label schizophrenia, ‘integration disorder’ reduced participants perceived ideation of dangerousness associated with the condition yet in fact increased social distance of public views. However, in contrast to these findings Tranulis (2013) acknowledged that participants based their attitudes on the descriptions of an individual with schizophrenia rather than the mental health diagnosis labels themselves. Other studies using alternative labels for mental health conditions have established conflicting results; Arthur et al (2010) conducted a study in Jamaica who used different words to indicate varying degrees of mental health severity of a range of vignettes constructed with the same description of a individual with schizophrenia, yet this study found that such labels had no association with social distance score proposing the possibility of other factors such as the symptoms depicted in within the vignettes influencing participants desire for social distance. Opposed to a study by Connolly (2011) who also used vignettes depicting an individual with schizophrenia; however, only one of the vignettes was labelled with the diagnosis schizophrenia whereas the other was labelled without a diagnosis. The results comprised from this study established that the vignette labelled with a diagnosis conveyed less desire for social distance than the vignette with no label. In comparison to Arthur et al (2010) study, Connolly (2011) reinforces that mental health diagnosis labels are influential for people when assessing social distance.

The initiative behind renaming schizophrenia as a potential strategy to reduce stigma is to attempt to eliminate any negative connotations people may have towards those with schizophrenia (Brabban, Morrison & Read, 2013). However, some still argue that there is not sufficient evidence to support the notion of renaming schizophrenia as a potential strategy of reducing the attached stigma (Yamaguchi et al, 2017).

Community attitudes towards mental health
The psychology behind how and what constitutes as an attitude in relation to stigmatising attitudes is articulated by  Schiffman & Kanuk, (2004) that perceived attitudes towards mental illnesses are of a psychological construct, devised of 3 main components according to the Cognitive-Affective-Conative Model (CAC Model). This model of social attitudes suggests that attitudes are constructed around the following three components: an affective component (concerning people’s emotions towards an attitude entity), a cognitive component (cornering people’s thoughts and beliefs towards an attitude entity) and a conative component (concerning people’s behaviour towards an attitude entity). With these apparent factors involved in the formation of negative attitudes, examination into how far attitudes towards those with a mental illness have developed overtime has been a focus for combating negative attitudes, misconceptions and the general lack of awareness held by the general population as a stigma reduction technique. Within context, community attitudes are the evaluations that people make about individuals diagnosed with a mental illness which are held by the remaining populace of communal society. It is such attitudes held by the remaining general population that have formulated various commonly held stereotypes about people with mental illness such as violence and incompetence where such discrimination can lead to social exclusion (Corrigan, 2000). It is proven by a substantial range of ongoing literature that the labels of certain mental illness, such as schizophrenia can carry a large summation of stigmatisation and global attitudes; due to an association of general misconceptions and perceived connotations and stereotyping (Corrigan, 2000) attached to the diagnosis schizophrenia. In existing literature, Van Dorn et al, (2005) documented that more contact with those with a diagnosis of schizophrenia is associated with positive attitudes held within the general population.

Desire for social distance
Social distance by large another form of discrimination and is best described as unwillingness for interpersonal contact with a particular group or person (Jorm & Oh, 2009). Within the field of psychology when referring to the term ‘desire for social distance’ it purports that an individual has a reluctance to interact within close proximity with those seemingly as established as an outsider within society. There has been various research into social distance on highly stigmatised outcast groups within society; with schizophrenia and severe mental health being one of those extensively debated. Reavley & Jorm (2011) conducted a telephone interview where participants were presented with a verbal vignette describing various mental health conditions such as: depression, early schizophrenia, chronic schizophrenia, post-traumatic stress disorder and social phobia. Participants were asked various questions during the interview about their attitudes towards the hypothetical person described in the vignette as well as questions assessing their desire for social distance. The results that were concluded from this study was that the severity of mental illness influenced negative attitudes and a greater sense of social distance; as the results revealed that out of all the mental health vignette options, chronic schizophrenia was more likely to be associated with negative attitudes such as: dangerousness and unpredictability and heightened desire for social distance.
 

Familiarity and mental health
Negative attitudes held by the general population can lead to an unwillingness when having to  socialise intimately with those whom have a form of mental illness; thus propositioning the initiative of social distance (Adewuya & Mkanjuola, 2008). Consistent evidence has demonstrated that those who do not have some form of academic knowledge yet are still in fact familiar with mental illnesses such as schizophrenia through having personal ties to people with a diagnosis of schizophrenia, express less desire for social distance when encountering an individual with schizophrenia, which leads to their proposal that if the breadth of familiarity of the general public is encouraged then stigmatization will decline (Angermeyer et al, 2004). There has been commodious research into various intervention techniques to reduce such stigmatised views where retrospective studies have indicated that a prior contact and a general greater breadth of knowledge improves attitude towards mental illnesses and is significantly associated with less-distancing behaviours (Stuart & Arboleda-Florez, 2001). Previous research over the years has demonstrated that those who posses familiarity with mental illness (i.e. by knowing someone with a mental health diagnosis), illustrate a strong association for factors such as; mental health related knowledge, attitudes and less desire for social distance (Evans-Lacko et al, 2013; Corrigan et al, 2012).Whereas, some studies have examined familiarity in the context of personal contact. In the context of familiarity with schizophrenia, personal contact signifies how an individual comes into contact with someone with the condition whether that is interacting with someone with the condition or observing someone at a distance. Personal contact research has shown that having contact with a person with a mental health condition does in fact reduce stigma (Schulze et al, 2003).

Renaming schizophrenia and familiarity
An area of stigma that seems to be unexamined is whether the effects of familiarity in combination with alternative labels for severe mental health conditions such as schizophrenia can replicate significant findings to tackle the attached stigmatizations surpassing the notion that only using one of the factors only would be sufficient enough for reducing general attitudes. Some studies have shown that familiarity and personal contact reduces stigma by presenting more positive attitudes towards schizophrenia (Anagnostopoulos & Hantzi 2011; Roth et al, 2000). Likewise with using alternative mental health diagnosis labels (Van Os (2009). The assumption that both factors harmonizing it yet to be examined. To date there has been a study by Yang et al (2012) in Japan used culturally formulated interpretations of the illness schizophrenia as labels for their vignettes such as ‘excessive thinking’. This study found that when an alternative label was used opposed to the use of the mental health diagnosis label schizophrenia, social distance was reduced when people were familiar with the condition only when the symptomology depicted in the vignette displayed no resemblance to a mental illness.

The primary focus for the current study is to assess whether the general population hold series of negative global attitudes about the mental health condition schizophrenia based on the use of interchangeable mental health diagnosis labels ‘salience syndrome’ and ‘schizophrenia’ and whether or not familiarity with the diagnosis minimises such perceived stigmatisation and social distance towards individuals with schizophrenia. The mental health diagnosis label ‘salience syndrome’ elected for this particular study as an interchangeable label of schizophrenia was opted due to existing literature proposing that it may be associated with less stigma than  a mental health label of ‘schizophrenia’.
The effect of both of the different mental health diagnosis labels and prior knowledge of the condition schizophrenia had on participant’s community attitudes were examined. In sum this study tested the following hypothesis; it was expected to find that there would be more positive scores on the community attitudes towards the mentally ill scale associated with the mental health diagnosis label ‘salience syndrome’ than the ‘schizophrenia’ label. In regards to familiarity, it was predicted that participants who have greater familiarity with the mental illness schizophrenia would present lower scores on the community attitudes towards the mentally ill scale thus indicating more positive attitudes towards the diagnosis schizophrenia. Furthermore, it was also predicted that those who have greater prior familiarity with the mental illness schizophrenia will not be as affected by an interchangeable mental health diagnosis label than those who have low familiarity on community attitude scores.

The effect of both of the different mental health diagnosis labels and prior knowledge of the condition schizophrenia had on participant’s social desirability were examined. It was also expected to find through an analysis of variance, that would be more positive scores on the social distance scale associated with the mental health diagnosis label ‘salience syndrome’ than ‘schizophrenia’. In regards to familiarity, it was predicted that participants who have greater familiarity with the mental illness schizophrenia would present lower scores on the social distance scale. Furthermore, it was also predicted that those who have greater prior familiarity with the mental illness schizophrenia will not be as affected by an interchangeable mental health diagnosis label than those who have low familiarity on social distance scores.

Method
Participants
This current study consisted of ninety nine participants recruited from the general population of an volunteer based sample who responded to online advertisements using social media. There were 26 incomplete survey responses 25.74% which were discarded from the final publication therefore, 73 responses were included in the analysis. 21 males and 52 females, aged between 19 and 84 (M= 47 Years, SD= 17.45 Years). For the present study, exclusion criteria utilised to exclude any participants under the age of 18 years.

Design
Two separate between-subjects two-way ANOVA’s were used on a sample of the general population. To factors were measured for both analyses; mental health diagnosis label (Schizophrenia/Salience syndrome) and level of familiarity (minimal/moderate/in-depth). The dependent variable for the first ANOVA conducted were scores on the community attitudes towards the mentally ill scale (CAMI); and the dependent variable for the second ANOVA conducted were scores on the social distance scale (SDS).

Materials
An online survey was conducted where participants received one of two self created vignettes meeting ICD-10 criteria for schizophrenia either labelled ‘schizophrenia’ or ‘salience syndrome’. (See Appendix 1.4)
Two self complete questionnaires were utilised to ascertain participant’s general attitudes towards the diagnosis of schizophrenia and their willingness to interact with those diagnosed:

The social distance scale (SDS), (Bogardus,1993). The SDS is a 7 item measure questionnaire which utilises a self 5 point likert from using a 5-point Likert scale ranging from (1=Definitely willing to 5=Definitely unwilling). For this particular study an overall score on the SDS was used in the analysis with a higher score indicating desire for social distance. The internal consistency of the scale was measured; the present study’s cronbach’s alpha for the SDS was .69. (See Appendix 1.5)

The community attitudes towards the mentally ill (CAMI), (Taylor & Dear, 1981). The CAMI is a 40 item measure questionnaire consisting of 4 sub scales: authoritarianism, benevolence, social restrictiveness and community mental health ideology. For this particular study an overall CAMI score was used in the analysis by summing up all the subscales with a higher score indicating negative attitudes thus more stigma against those with a mental illness. Statement responses were numerically reversed depending on which of the statements opposed the nature of the of the sub scales. The CAMI scale utilises a 5-point Likert scale from (1=Strongly agree to 5=Strongly disagree). The internal consistency of the scale was measured; the present study’s cronbach’s alpha for the CAMI was .92. (See Appendix 1.6)

A short demographic questionnaire was also used asking participants their age, sex, educational attainment, familiarity and indication of self knowledge of schizophrenia. In this particular study, familiarity with schizophrenia was measured using the following item: “Do you know anybody with the clinical diagnosis schizophrenia?” with a choice of “yes” or “no”. If familiarity was disclosed, a further question asked those to indicate their level of knowledge. Potential response options included the following: “minimal knowledge”, “moderate knowledge” or “in-depth knowledge”.

 Procedure
The participants recruited to participate within the study were informed about the study via social media platforms where participants volunteered to par take within the study. Through the use of these online advertisements potential participants where briefly informed on what the study was about in relation to investigating attitudes towards mental health conditions; then asked participants who were willing to participate to access the survey link provided. The survey was conducted online using Qualtrics an online survey software. Once the survey was accessed via the given link the first page participants were directed to was the information page, informing participants of the nature of the study, confidentiality, anonymity and the right to refuse answering any questions they do not wish as well as, the right to withdraw from the study were emphasised before participation; followed by a consent form where all statements had to be selected in order to continue. The demographic questionnaire was used to ascertain participant’s familiarity and level of knowledge of schizophrenia. Participants were then presented with one of two short vignettes at random either titled ‘schizophrenia’ or ‘salience syndrome’. Based on which of the vignettes they were previously presented with, participants were then asked to fill in the social distance scale indicating a response which best described their willingness for each of the statements. Participants were then to fill in a second questionnaire, the community attitudes towards the mentally ill questionnaire in order to gather the nature of participant’s general attitudes towards mental illness.
 

Results

Table 1: Descriptive statistics for the Demographics variables.

NOTE: Educational attainment: 4participant responses missing (5.5%).

An independent factorial ANOVA was conducted; to analyse whether scores of community attitudes towards the mentally ill are affected by mental health diagnosis label (Schizophrenia/Salience syndrome) and level of familiarity (minimal/moderate/in-depth). A non-significant main effect of mental health diagnosis label was found (F (1, 9) = .286; p = .606; ηp² =.031) demonstrating that by presenting all participants with the same style vignette featuring schizophrenic like symptoms,  although using interchangeable mental health diagnosis labels it did not alter participants general attitudinal consensus towards schizophrenia. Additionally there was a non-significant main effect of level of familiarity (F (2, 9) = .631; p = .554; ηp² = .123) demonstrating that although participants stated having a varied level of prior knowledge of schizophrenia it did not have any influential baring on participants general attitudes towards schizophrenia.
The interaction of mental health diagnosis label and level of familiarity was also non-significant (F (1, 9) = 1.302; p = .282; ηp² = .126) demonstrating that participants general attitudes towards schizophrenia do not vary with interchangeable mental health diagnosis labels depending on participants level of prior knowledge.
As can be seen in Table 2, there is a clear distinction that mental health diagnosis label and familiarity did not revolutionise participant’s scores on the community attitudes towards the mentally ill scale.

Table 2: Shows summary of AVOVA of CAMI scores.

NOTE: SS = Sum of Squares, MS = Mean Square, ηp² = Partial Eta Squared
Statistical Significance  * = P-Value < 0.005, Statistical Significance ** = P-Value < 0.001

An independent factorial ANOVA was conducted; to analyse whether social distance scores are affected by mental health diagnosis label (Schizophrenia/Salience syndrome) and level of familiarity (minimal/moderate/in-depth). A non-significant effect of mental health diagnosis label was found (F (1, 9) = .181; p = .680; ηp² =.020) demonstrating that by presenting all participants with the same style vignette featuring schizophrenic like symptoms,  although using interchangeable mental health diagnosis labels it did not alter participants desire for social distance.
Additionally there was a non-significant main effect of level of familiarity (F (2, 9) = .099; p = .907; ηp² = .021) demonstrating that although participants stated having a varied level of prior knowledge of schizophrenia it did not have any influential baring on desire for social distance.
The interaction of mental health diagnosis label and level of familiarity was also non-significant (F (1, 9) = 1.040; p = .334; ηp² = .104) demonstrating that participants desire for social distance does not vary with interchangeable mental health diagnosis labels depending on participants level of prior knowledge of schizophrenia.

As can be seen in Table 3, there is a clear distinction that mental health diagnosis label and familiarity did not revolutionise participant’s scores on the social distance scale.
 

Table 3: Shows summary of AVOVA of SDS.

NOTE: SS = Sum of Squares, MS = Mean Square, ηp² = Partial Eta Squared
Statistical Significance  * = P-Value < 0.005, Statistical Significance ** = P-Value < 0.001

Discussion
The primary purpose of this study was to acquire participants to engage in an online survey; exploring whether general attitudes and desire for social distance towards schizophrenia are contrary when associated with interchangeable labels of mental health diagnosis. As well as, whether certain levels of familiarity present positive general attitudes and lessen the desire for social distance towards schizophrenia thus, decreasing stigmatisations.

The mental health diagnosis label ‘salience syndrome’ did not appear to confer more positive scores on the community attitudes towards the mentally ill scale than the ‘schizophrenia’ label thus, lower community attitude scores. The present study presented no credible evidence of the consensus that the general population would posses more positive attitudes towards schizophrenia when the ‘salience syndrome’ label was used rather than the current diagnosis label ‘schizophrenia’. This was probably due to how people perceive the symptoms and characteristics of schizophrenia rather than the diagnosis label itself. This supports findings by Tranulis (2013) who stated that participants based their attitudes on the descriptions of an individual with schizophrenia rather than the interchangeable mental health diagnosis labels. This was found by using a similar methodology as the present study; through the use of vignettes Tranulis (2013) described the symptomatic experiences followed by unusual experiences and irrational thoughts of a hypothetical person with schizophrenia. However, the findings from the present study contradict more recent research who found using an alternative mental health diagnosis label for schizophrenia ‘integration disorder’ actually reduced participants perceived ideation of dangerousness associated with the condition (Ellison et al, 2015).

As well as community attitudes the mental health diagnosis label ‘salience syndrome’ did not appear to confer more positive scores on the social distance scale than the ‘schizophrenia’ label thus presented lower social distance scores. The present study presented no credible evidence of the consensus that the general population would posses less desire for social distance from an individual with schizophrenia when the ‘salience syndrome’ label was used rather than the current diagnosis label ‘schizophrenia’. Likewise the present study supports the conclusion of Ellison et al, (2015) that by using ‘integration disorder’ as an alternative mental health diagnosis label in comparison to the diagnosis label schizophrenia, which was hypothesised to reduce social distance in fact in this case increased social distance of public views. To date there is very little research into how using interchangeable mental health diagnosis labels will affect social distance. Nevertheless, it is arguable that by using vignettes to depict an individual with a diagnosis of schizophrenia may influence responses that perhaps other methodologies would not. It is noticeable that the results from this particular study reflect similarities of those conducted by Arthur et al (2010); who by using different words to indicate varying degrees of mental health severity found that the general populations perspective of social distance towards an individual with schizophrenia are not continuously   dependant on the classification of diagnostic labels of mental health conditions. Therefore, the results concluded that although using ‘salience syndrome’ as an alternative label of schizophrenia, the increase in desire for social distance may be due to how people have taken into considerate the symptomatic inventory of criteria used, to perceive schizophrenia negatively rather than the label; very much like the results found for community attitudes (Tranulis, 2013).

In regards to familiarity, the predicted result outcome of this experiment inferred that those who have greater familiarity with the mental illness schizophrenia would present more positive attitudes on the community attitudes towards the mentally ill scale. Of which the present study presented no credible evidence that prior familiarity with the condition improve attitudes towards schizophrenia. With vast literature supporting the notion that a greater breadth of knowledge due to prior familiarity improves attitudes towards mental illnesses (Stuart & Arboleda-Florez, 2001);  the present results clearly contradicts those findings of  Van Dorn et al, (2005) who documented that amongst the general population those who have more contact with someone with schizophrenia thus, exhibiting more familiarity with the condition do demonstrate positive attitudes in comparison to those who have little to no familiarity (Angermeyer et al, 2004).
Reflecting on the hypothesis that greater familiarity with the condition schizophrenia would in fact lessen people’s desire for social distance amongst the general population; still seems to be a promising premise that other theorists have supported (Anagnostopoulos & Hantzi, 2011). Of which, the present study in fact contradicts the results revealed as there was  no credible evidence that a greater level of prior knowledge of the condition schizophrenia reduced scores on the social distance scale than for those who indicate a slighter knowledge.

It is apparent for this particular study that mental health diagnosis labels and prior familiarity when in cohesion, also did not lessen people’s desire for social distance. Through an analysis of variance, the results demonstrated that there was no statistical significance of an interaction between the interchangeable mental health diagnosis labels ‘salience syndrome’ and ‘schizophrenia’ and those who indicate greater prior familiarity with the condition on community attitudes. Consequently, the present study presented no credible evidence that attitudes towards schizophrenia will not be as affected for those who indicate a greater prior knowledge of schizophrenia than those who indicate low familiarity when using an interchangeable mental health diagnosis label. In comparison to existing findings it is challenging to find such studies that provide a significant statistical outcome as there is little literature that focuses on the affect of mental health diagnosis labels and familiarity. Yang et al (2012) found a significant result when both contributing factors were accounted for lessening participant’s desire for social distance; however, it was stated that the value of significance ought to be detracted as this result was found when the description of the vignette did not depict any mental health symptoms. When examining social distance the predicted result outcome of this experiment inferred that the general population’s desire for social distance would not be as affected when the two interchangeable mental health diagnosis labels ‘salience syndrome’ and ‘schizophrenia’ when a greater prior familiarity was indicated than those with lower familiarity. The results established by the present study were similar to those previously stated as there was no credible evidence that whether choosing to address the condition as ‘schizophrenia’ or ‘salience syndrome’, social distance scores for those with greater familiarity should not fluctuate. This could suggest that renaming schizophrenia is not as valuable as we think. By using a schizophrenic individual vignette either labelled ‘schizophrenia’ or with no diagnosis label at all Connolly (2011) hypothesised that having a label of ‘schizophrenia’ would increase participants social distance scores however, it was found that in comparison to vignette with no diagnostic label, the vignette labelled ‘schizophrenia’ denoted less desire for social distance from those with schizophrenia.  Therefore, it may be fair to say that the results found in this particular study support those findings by Connolly (2011). For the purpose of the present study, by using the mental health diagnosis label ‘schizophrenia’ with the general population already have some knowledge as to the symptoms and connotations attached to a person with schizophrenia would however, using the mental health diagnosis label ‘salience syndrome’ would deem individuals more likely to show a desire for social distance if they have not heard of what ‘salience syndrome’ is. Thus, it is speculated that the unknown spectacle of the condition which may have very little diagnostic relevance if any to those of the general population would in fact increase social distance. If this is a viable explanation into how the general population perceive diagnostic labels of mental health conditions; it would lead to questioning whether renaming schizophrenia to an alternative mental health diagnosis label would efforts of expanding the knowledge of the general population of the condition with the same classification of symptoms including: delusional thinking, hallucinations, disorganised speech and peculiar behaviour characteristics (American Psychiatric Association, 2013), outcome and prognosis lead us right back to where we stand today. Not in fact reducing the stigmatisations attached to the condition itself but, by all means endeavouring to validate any beneficial reasoning to replace the name of schizophrenia in the first place. Of which contradicts the beliefs of Van Os (2009), that renaming schizophrenia as the label ‘salience syndrome’ would influence the general population that the condition is not diverse in the normality of human behaviour.

There are numerous limitations of the present study worthy of acknowledgement; the first obvious limitation is in reference to the data. The volume of participant responses were not as substantial as originally sought after with numerous responses being disregarded from the finally analysis due to incomplete (N=26). With the controversy of whether mental health diagnosis labels of schizophrenia and familiarity has any association with community attitudes and desire for social distance, there is speculation as to whether a larger volume of participant responses indeed a more suitable representation of the general population, would be in agreement with such studies conducted by Stuart & Arboleda-Florez, (2001) in providing a significant result. Therefore, future studies should be conducted with a larger sample in order to validate the obscurities in existing literature to determine whether there is an association between mental health diagnosis labels and familiarity on community attitudes and social distance. There has been ample debate over the validity of using a 5 point likert scale; both of the scales used in the present study are based on a 5 point likert scale which both includes a neutral response option for participants which could of hindered a significant association between mental health diagnosis labels and familiarity on community attitudes and social distance. This could mean that participants in the present study may have had a tendency to gravitate towards the neutral option with the effect of social desirability bias. Due to the emotive subject matter, this could of lead to participants feeling reluctant to select an answer which represents a socially undesirable answer causing a false response which does not reflect their true beliefs. Therefore, for the purpose of replicating this study perhaps other scales measuring attitudes and social distance could be use or further developing the existing CAMI and SDS eliminating social desirability bias with the removal of the neutral response.
Overall the present study has concluded that by using ‘salience syndrome’ as an alternative label for schizophrenia was of no benefit in reducing negative community attitudes or desire for social distance; neither did having a greater level of prior knowledge of  the condition lessen negative attitudes and social distance amongst the general population consequently failing to reject the null hypotheses. In light of these findings, it appears that the possibility of renaming schizophrenia in attempts to reduce stigma amongst the general population is not a compelling strategy for targeting such a vast and challenging issue; and to ponder the question whether renaming schizophrenia has any beneficial proposition as a stigma reduction technique is still questionable. For that reason in agreement with Yamaguchi et al, (2017) that the overall associations and benefits between renaming schizophrenia and stigma reduction has not yet been fully clarified within empirical literature as the same for social distance. Furthermore, this experiment has provided a substantial base for further investigation into whether the possibility of renaming schizophrenia is advantageous in reducing the stigma attached to the condition in the domains of attitudes and social distance. To follow on from this, whether alternative labels such as Ellison et al, (2015) proposal of ‘integration disorder’ can lessen stigma across all domains.

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