Body image, internalized stigma and enacted stigma predict psychological distress in women with breast cancer: A serial mediation model

Abstract

Aims To investigate the roles of total stigma, enacted stigma, and internalized stigma in the prediction of psychological distress among breast cancer patients, and to evaluate the mediating effect of body image in this process. Design Cross‐sectional. Methods Between Oct‐2014 to May‐2015, a cross‐sectional study was conducted with participation of 223 patients from three cancer centres located in Tehran, Iran. The study variables were assessed using the stigma scale for chronic illnesses 8‐item version (SSCI‐8), body image scale (BIS), and depression anxiety stress scale (DASS‐21). Structural equation modelling using MLR estimator was employed based on the two‐step procedure to validate both the full measurement models and the structural models. Five models were tested to determine predictability of all stigma constructs for psychological distress, including stress, anxiety, and depression, through the mediation of body image. Three equivalent models were further examined to re‐evaluate the direction of the relationships. Results Psychological distress and body image were largely predicted by total stigma, enacted stigma, and internalized stigma. The effect of stigma on psychological distress was mediated through body image. In a serial mediation model, the significance of the pathway of enacted stigma > internalized stigma > body image > psychological distress was confirmed. The serial model in which internalized stigma precedes body image was also supported by the equivalent models. Conclusion Stigma has been identified as a major source of psychological distress among women with breast cancer. Enacted stigma not only psychologically disturbs the patients but also triggers a chain of other identity transformations (i.e. internalization of stigma and distortion of body image), their ultimate result being a full‐blown psychological distress. Impact Both enacted and internalized stigma distorts breast cancer patients' perception of their body image, which in turn renders them psychologically distressed. The serial process of enacted stigma, internalized stigma, and body image plays an important role in perpetuating distress in these patients. To break this chain of psychological consequences and for interventions to have a greater impact on overall well‐being of patients, the effect of enacted stigma on distress via the sequence of two mediators needs to be specifically targeted at each stage.

Coping with Stress in Neoplastic Diseases

“…Unfortunately, patients in this group often adopt negative strategies, such as substance use and discontinuation of activity. These results are in line with the study by Amini-Tehrani et al, who directly presented the consequence of triggering the chain of identity changes (including distortion of body image), which ultimately result in full-scale psychological distress [ 16 ]. The thesis related to the distortion of body image was also confirmed in scientific studies, e.g., by Brandberg et al [ 17 ].…”

Stigma and Quality of Life in Women With Breast Cancer: Mediation and Moderation Model of Social Support, Sense of Coherence, and Coping Strategies

“…Additionally, social and cultural contexts largely impact HRQoL ( Wilson and Cleary, 1995 ; Gerasimčik-Pulko et al, 2009 ). In Iran, where women with breast cancer have reported a moderate HRQoL (Salehoddin Bouya et al, 2018 ), there is rising concern about the stigmatization of the condition in patients and the public ( Khakbazan et al, 2014 ; Najmabadi et al, 2014 ; Daryaafzoon et al, 2020 ; Amini-Tehrani et al, 2021 ).…”

Research on body image cognition, social support and illness perception in breast cancer patients with different surgical methods

“…Hence, it is worth investigating the impact of mastectomy and breast conservation surgery on Chinese patients' body image cognition. On the other hand, an emerging number of psychosocial oncology research mainly focused on the relationship between body image cognition and emotional reaction (Rosenberg et al, 2020;Zamanian et al, 2021), shame (Trindade et al, 2018) and quality of life (Aydın Sayılan and Demir, 2020;Rosenberg et al, 2020) whereas the influence of illness perception on body image cognition has rarely been explored.…”