پیشگیری صدمات بدنی

Bullock SH(1), Jones BH, Gilchrist J, Marshall SW.

Author information:
(1)U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland, USA. Steven.H.Bullock@us.army.mil

BACKGROUND: The Military Training Task Force of the Defense Safety Oversight
Council chartered a Joint Services Physical Training Injury Prevention Working
Group to: (1) establish the evidence base for making recommendations to prevent
injuries; (2) prioritize the recommendations for prevention programs and
policies; and (3) substantiate the need for further research and evaluation on
interventions and programs likely to reduce physical training-related injuries.
EVIDENCE ACQUISITION: A work group was formed to identify, evaluate, and assess
the level of scientific evidence for various physical training-related injury
prevention strategies through an expedited systematic review process. Of 40
physical training-related injury prevention strategies identified, education,
leader support, and surveillance were determined to be essential elements of a
successful injury prevention program and not independent interventions. As a
result of the expedited systematic reviews, one more essential element (research)
was added for a total of four. Six strategies were not reviewed. The remaining 31
interventions were categorized into three levels representing the strength of
recommendation: (1) recommended; (2) not recommended; and (3) insufficient
evidence to recommend or not recommend.
EVIDENCE SYNTHESIS: Education, leadership support, injury surveillance, and
research were determined to be critical components of any successful injury
prevention program. Six interventions (i.e., prevent overtraining, agility-like
training, mouthguards, semirigid ankle braces, nutrient replacement, and
synthetic socks) had strong enough evidence to become working group
recommendations for implementation in the military services. Two interventions
(i.e., back braces and pre-exercise administration of anti-inflammatory
medication) were not recommended due to evidence of ineffectiveness or harm, 23
lacked sufficient scientific evidence to support recommendations for all military
services at this time, and six were not evaluated.
CONCLUSIONS: Six interventions should be implemented in all four military
services immediately to reduce physical training-related injuries. Two strategies
should be discouraged by all leaders at all levels. Of particular note, 23
popular physical training-related injury prevention strategies need further
scientific investigation, review, and group consensus before they can be
recommended to the military services or similar civilian populations. The
expedited systematic process of evaluating interventions enabled the working
group to build consensus around those injury prevention strategies that had
enough scientific evidence to support a recommendation.

Published by Elsevier Inc.

پیشگیری صدمات بدنی

Gill TM(1), Pahor M(2), Guralnik JM(3), McDermott MM(4), King AC(5), Buford
TW(2), Strotmeyer ES(6), Nelson ME(7), Sink KM(8), Demons JL(8), Kashaf SS(9),
Walkup MP(10), Miller ME(10); LIFE Study Investigators.

Collaborators: Pahor M, Guralnik JM, Leeuwenburgh C, Caudle C, Crump L, Holmes L,
Lee J, Lu CJ, Miller ME, Espeland MA, Ambrosius WT, Applegate W, Beavers DP,
Byington RP, Cook D, Furberg CD, Harvin LN, Henkin L, Hepler J, Hsu FC, Lovato L,
Roberson W, Rushing J, Rushing S, Stowe CL, Walkup MP, Hire D, Rejeski W, Katula
JA, Brubaker PH, Mihalko SL, Jennings JM, Hadley EC, Romashkan S, Patel KV, Bonds
D, McDermott MM, Spring B, Hauser J, Kerwin D, Domanchuk K, Graff R, Rego A,
Church TS, Blair SN, Myers VH, Monce R, Britt NE, Harris MN, McGucken AP, Rodarte
R, Millet HK, Tudor-Locke C, Butitta BP, Donatto SG, Cocreham SH, King AC, Castro
CM, Haskell WL, Stafford RS, Pruitt LA, Berra K, Yank V, Fielding RA, Nelson ME,
Folta SC, Phillips EM, Liu CK, McDavitt EC, Reid KF, Kim WS, Beard VE, Manini TM,
Pahor M, Anton SD, Nayfield S, Buford TW, Marsiske M, Sandesara BD, Knaggs JD,
Lorow MS, Marena WC, Korytov I, Morris HL, Fitch M, Singletary FF, Causer J,
Radcliff KA, Newman AB, Studenski SA, Goodpaster BH, Glynn NW, Lopez O, Nadkarni
NK, Williams K, Newman MA, Grove G, Bonk JT, Rush J, Kost P, Ives DG, Kritchevsky
SB, Marsh AP, Brinkley TE, Demons JS, Sink KM, Kennedy K, Shertzer-Skinner R,
Wrights A, Fries R, Barr D, Gill TM, Axtell RS, Kashaf SS, de Rekeneire N,
McGloin JM, Wu KC, Shepard DM, Fennelly B, Iannone LP, Mautner R, Barnett TS,
Halpin SN, Brennan MJ, Bugaj JA, Zenoni MA, Mignosa BM, Williamson J, Sink KM,
Hendrie HC, Rapp SR, Verghese J, Woolard N, Espeland M, Jennings J, Pepine CJ,
Ariet M, Handberg E, Deluca D, Hill J, Szady A, Chupp GL, Flynn GM, Gill TM,
Hankinson JL, Fragoso CA, Groessl EJ, Kaplan RM.

OBJECTIVE: To test whether a long term, structured physical activity program
compared with a health education program reduces the risk of serious fall
injuries among sedentary older people with functional limitations.
DESIGN: Multicenter, single blinded randomized trial (Lifestyle Interventions and
Independence for Elders (LIFE) study).
SETTING: Eight centers across the United States, February 2010 to December 2011.
PARTICIPANTS: 1635 sedentary adults aged 70-89 years with functional limitations,
defined as a short physical performance battery score ≤ 9, but who were able to
walk 400 m.
INTERVENTIONS: A permuted block algorithm stratified by field center and sex was
used to allocate interventions. Participants were randomized to a structured,
moderate intensity physical activity program (n=818) conducted in a center (twice
a week) and at home (3-4 times a week) that included aerobic, strength,
flexibility, and balance training activities, or to a health education program
(n=817) consisting of workshops on topics relevant to older people and upper
extremity stretching exercises.
MAIN OUTCOME MEASURES: Serious fall injuries, defined as a fall that resulted in
a clinical, non-vertebral fracture or that led to a hospital admission for
another serious injury, was a prespecified secondary outcome in the LIFE Study.
Outcomes were assessed every six months for up to 42 months by staff masked to
intervention assignment. All participants were included in the analysis.
RESULTS: Over a median follow-up of 2.6 years, a serious fall injury was
experienced by 75 (9.2%) participants in the physical activity group and 84
(10.3%) in the health education group (hazard ratio 0.90, 95% confidence interval
0.66 to 1.23; P=0.52). These results were consistent across several subgroups,
including sex. However, in analyses that were not prespecified, sex specific
differences were observed for rates of all serious fall injuries (rate ratio
0.54, 95% confidence interval 0.31 to 0.95 in men; 1.07, 0.75 to 1.53 in women;
P=0.043 for interaction), fall related fractures (0.47, 0.25 to 0.86 in men;
1.12, 0.77 to 1.64 in women; P=0.017 for interaction), and fall related hospital
admissions (0.41, 0.19 to 0.89 in men; 1.10, 0.65 to 1.88 in women; P=0.039 for
interaction).
CONCLUSIONS: In this trial, which was underpowered to detect small, but possibly
important reductions in serious fall injuries, a structured physical activity
program compared with a health education program did not reduce the risk of
serious fall injuries among sedentary older people with functional limitations.
These null results were accompanied by suggestive evidence that the physical
activity program may reduce the rate of fall related fractures and hospital
admissions in men.Trial registration ClinicalsTrials.gov NCT01072500.

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
http://group.bmj.com/group/rights-licensing/permissions.

پیشگیری صدمات بدنی

PMCID: PMC4772786

Whoops!

We are sorry, but we lost this page.

Worry not, our web site robots are sending us the message as we speak and we’ll be right on it soon.

© 2019 IntechOpen. All rights reserved.

Among the macronutrients, phosphorus, which is present in soil and plants nearly exclusively as orthophosphate anion (P) and its esters with organic alcohols, has, by far, the strongest affinity to the soil solid phase and consequently, the lowest solubility in the soil solution. In soil chemistry, the term buffering or buffer power is used to describe the intensity of bonding to the soil solid phase, which is described by the adsorption or desorption curve. High buffering or buffer power indicates that most of the added nutrient is bound to the solid phase and that the equilibrium soil solution concentration is low. Soils with high P buffering are defined as P-fixing soils. Such soils may contain high quantities of P; however, because of high concentration of P-sorbing sites, the P equilibrium soil solution concentration is low or even very low, sometimes near zero. The concentration or precisely the activity of P in the soil solution is important for the P acquisition of higher plants from soil because P is transported to the roots almost exclusively within the soil solution via diffusion [17, 18]. The diffusive flux strongly depends on the initial P concentration of the soil solution and consequently, the P concentration gradient within the rhizosphere soil solution (see for details [17, 18, 19]. Often, for maximum yield, higher plants need P soil solution concentrations above 1–5 μM P depending on the rooting density, the formation of root hairs, the root:shoot ratio and the formation of mycorrhiza. However, at very low P soil solution concentrations, an increase in the P absorbing root surface does not promote the acquisition of P adequately.پیشگیری صدمات بدنی

Under these conditions, strategies to increase the rhizosphere soil solution concentration of P by root exudates (chemical P mobilization) are promising and the central way to acquire P from strong P.

Several types of root exudates may increase the P solubility in soil and consequently increase the acquisition of P by the roots of higher plants.

As an adaption to P deficiency, plants can increase the efflux of protons followed by the acidification of the rhizosphere [11], they can increase the release of reducing agents (e.g., Tomasi et al. [13]), and they can increase the efflux of di- and tricarboxylates (see for a review, Gerke [17]).

The release of carboxylates is by far the most important way to acquire P even in P-fixing soils [17, 20].

To support this statement, information on the carboxylate efflux of different plant species and genotypes, the accumulation of carboxylates in the rhizosphere, the effect of carboxylates on the mobilization/dissolution of soil P and the acquisition of mobilized P by higher plants are required.

Proton release and carboxylate release are separate mechanisms in higher plants [15, 16]. However, often carboxylate and proton efflux is a coupled reaction to P deficiency.

As a result of P deficiency, many plant species show an increased carboxylate efflux, for example, white lupin [1, 21, 22, 23], alfalfa [24, 25], spinach [24, 26], chickpea [23]; red clover [24], yellow lupin [21, 27], radish buckwheat [28] and many members of the Proteaceae [29, 30] and of the Cyperaceae [31].

Many graminaceous species are considered to be ineffective in carboxylate excretion, but some graminaceous species show an increased carboxylate efflux to avoid Al- toxicity [32, 33, 34, 35].

In buckwheat, oxalate efflux was increased during Al- toxicity [36].

Whether and to which extent Al- toxicity induced carboxylate excretion is controlled by reduced P acquisition or affects P acquisition is unknown.

The release of carboxylates by dicotyledonous plant species is not uniform along the root but is concentrated on the region behind the root tips [24, 26, 37, 38, 39].

The carboxylate release strongly depends on the P status of the plants and may be by a factor of 10–100 higher in P-deficient plants compared to high P plants.

Keerthisinghe et al. [40] found a very high citrate release in fully developed cluster roots of white lupin with a maximum efflux of about 6.1 [nmol h−1 cm −1], decreasing in younger and old cluster root segments by a factor of 10 or even more.

Neumann et al. [41] confirmed these results; however, Watts and Evans (1999) measured a maximum citrate in cluster roots of white lupin of 33 [nmol min−1 m−1], which is about three times higher than the values reported by Keerthisinghe et al. [40].

Yellow lupin, a plant species that also forms cluster roots [21, 27], exhibits a maximum citrate efflux within the cluster roots of about 70–80% than that of the cluster roots of white lupin [27].

Cluster roots of the Proteaceae, for example, Hakea prostrata shows a carboxylate efflux of cluster roots, which is much higher than that of the white lupin [31, 42]. In Hakea undulate, malate is the main carboxylate, which is excreted with a root efflux being two times higher than the citrate efflux in white lupin [43]. Members of the Cyperaceae form “dauciform” roots as an adaption to P deficiency, which exhibit carboxylate efflux rates which are similar to the cluster roots of Proteaceae species [31].

Also, plant species that do not form cluster or dauciform roots can show a high carboxylate efflux during P deficiency. The region of high carboxylate efflux is often restricted to about 1–2 mm behind the root tips. For example, Beißner [37] showed for sugar beet, an increased oxalate efflux during P deficiency, the carboxylate efflux being by a factor of 3–4 higher, 1–2 mm behind the root tips, compared to the overall efflux of the whole root system.

Gerke [24] investigated the carboxylate efflux of several plant species, grown in quartz sand at four levels of P supply (Figures 1–6).

Carboxylate efflux by alfalfa (Medicago sativa L.) as affected by shoot P concentrations. (Modified from Gerke [24]).

Carboxylate efflux by red clover (Trifolium pratense L.) as affected by shoot P concentrations. (Modified from Gerke [24]).

Carboxylate efflux by spinach (Spinacia oleracea L.) as affected by shoot P concentrations. (Modified from Gerke [24]).

Carboxylate efflux by white clover as affected by shoot P concentrations. (Modified from Gerke [24]).

Carboxylate efflux by Chinese cabbage as affected by shoot P concentrations. (Modified from Gerke [24]).

Carboxylate efflux by ryegrass (Lolium perenne L.) as affected by shoot P concentrations. (Modified from Gerke [24]).

As the shoot P concentrations decreased, the efflux of carboxylates increased in all plant species was investigated (Figures 1–6).

However, the main carboxylates differed between the plant species. In legumes such as white clover, red clover or alfalfa, citrate is the dominant anion, whereas in spinach, oxalate is dominant and in the Brassicaceae species, Chinese cabbage (Brassica Chinensis), malate is dominant. Also, in rape, malate is the dominant anion [38].

In graminaceous species such as rye grass, the carboxylate efflux is extremely low, even at strong P deficiency (Figure 6), whereas especially in alfalfa and red clover, the overall citrate efflux was very high under P deficiency (Figures 1 and 2).

A high or even very high carboxylate efflux by roots of P-deficient plants is no guarantee for its accumulation within the rhizosphere soil. Carboxylates which are excreted into the soil solution are easily degradable C- source for soil microorganisms, which sometimes has been taken as an argument for the questioning of the relevance of carboxylates for P acquisition in soil (see e.g., the review of Richardson et al. [44]). However, the same review group of Richardson et al. [44] simplified the role of carboxylates in the rhizosphere to the question of carboxylate concentration in the soil solution assuming the soil solution being the main reservoir for carboxylates. However, the interaction of the excreted carboxylates and the soil solid phase is decisive for its effect on soil P solubility and the P acquisition by the plants in P-fixing soils.

The carboxylate concentration in the soil solution depends on the carboxylate excretion and the buffering of the carboxylates in soil and is not very relevant. Relevant for P mobilization is the concentration of carboxylates at the soil solid phase. The sorbed carboxylates can desorb P by occupying the P-sorption sites, and they can induce dissolution processes of P-sorbing surfaces such as Al (Fe)-(hydr)oxides or humic-Al(Fe) complexes [45, 46].

The result of these reactions between carboxylates and the soil solid phase is an increase in the P soil solution concentrations as well as an increase in Fe and Al solubility, which was experimentally shown for cluster root rhizosphere soil solution of white lupin [47] and is often reported in model experiments (e.g., Fox et al. [48]; Takeda et al. [49]; Gerke [46]).

Di- and tricarboxylates in the soil solution are easily degraded by microorganisms. If the excreted carboxylate is bound to the rhizosphere soil solid by a fast adsorption reaction, carboxylate degradation is strongly retarded.

Boudot [50] and Jones and Edwards [51] showed that the sorption of carboxylates to alumosilicates, Al-oxides and Fe- oxides strongly prevented microbial degradation. Boudot [50] investigated the effect of 14C-citrate adsorption to Al containing soil minerals. Free citrate was mineralized to about 70–80% within 10 days. At a high Al/citrate ratio, adsorption of citrate decreased the mineralization of citrate to zero. Similar results were found by Jones and Edwards [51] in the system citrate/Fe-oxides. Boudot [50] also showed that the formation of Al-citrate complexes in the solution strongly reduced citrate mineralization.

It has sometimes been speculated that acidification of the rhizosphere, for example, by legumes may reduce carboxylate mineralization within the rhizosphere soil (e.g., Lambers et al. [52]). At present, the effect of acidification on carboxylate adsorption and its consequent effect on P mobilization are estimated to be more important (Gerke, 2000a).

The accumulation of carboxylates in the rhizosphere is remarkable. Dinkelaker et al. [1] found more than 50 μmol citrate/g soil in the cluster root rhizosphere of white lupin. Gerke [17, 24] found between 12 and 88 μmol citrate/g soil in the cluster root rhizosphere of white lupin grown in different soils at different P levels depending on the method of citrate determination.

Often, carboxylates in the rhizosphere soil of different plant species are quantified after extraction with mild extractants, such as distilled water [53, 54], dilute salt solutions [23, 55, 56] or dilute acid [57], leading to a low recovery of the carboxylates. Gerke et al. [47] found citrate concentrations in the cluster root rhizosphere of between 66 and 88 [μmol citrate/g soil] determined by direct infrared spectroscopy (DRIFT spectroscopy), whereas the quantity of citrate extracted with water was below the detection limit.پیشگیری صدمات بدنی

Cluster roots are a peculiar adaption of relatively few plant species, among them, both white lupin and yellow lupin are cultivated plant species.

In the noncluster root forming plant species, red clover, Gerke and Meyer [58] showed a citrate accumulation of more than 12 [μmol citrate/g soil] in close proximity to the roots of P-deficient plants.

Several carboxylates can strongly increase the P soil solution concentration.

This was relatively shown earlier, for example, by Earl et al. [2] and Lopez-Hernandez et al. [3].

More detailed results were reported by Gerke [24] and Gerke et al. [59].

Often, with increasing carboxylate application and accumulation at the soil solid phase, the P concentrations in the soil solution increase exponentially (Figures 7 and 8) [59].

Relation between the citrate concentration in soil and the P solubility at different pH in a Ferralsol. (Modified from Gerke [24]).

Relation between the citrate concentration in soil and the P solubility at different pH in a humic Podzol. (Modified from Gerke [24]).

From Figures 7 and 8 it can be seen that changes in soil pH alone have only a minor impact on the soil P solubility but pH changes strongly affect the effectiveness of citrate to mobilize soil P. The exponential relation can also be shown, for example, for oxalate [24, 37].

Table 1 shows that citrate and, to some extent, oxalate are very efficient in mobilizing soil P, whereas malate and oxaloacetate are relatively inefficient.

Maximum phosphate and iron + aluminum mobilization by organic anions.

Many experimental results demonstrate that P deficiency in higher plants increases the carboxylate efflux. Also, many experimental results show that citrate, oxalate, to some extent, malate and other carboxylates can mobilize P in P-fixing soils.

The separate views on the physiology of carboxylate excretion and root morphology or, on the other hand, the rhizosphere chemistry of carboxylates and its impact on the P solubility in soil does not prove the relevance of carboxylate excretion on the P acquisition of higher plants.

The combination of both views, including carboxylate efflux, the accumulation of carboxylates in the rhizosphere soil, the chemistry of P mobilization and the uptake of mobilized P by the roots may help to evaluate the contribution of carboxylate excretion to P acquisition by higher plants.

For this purpose, mathematical models are a useful tool. Also, such models allow, by the aid of sensitivity analysis, to evaluate the contribution of different parameters to the acquisition of P by higher plants.

Nye [60, 61] developed a mathematical model to quantitatively describe the influx of P as affected by the efflux of mobilizing agents.

Gerke [24] was the first who used the mathematical framework of Nye [60, 61] to quantify the influx of mobilized P as a result of a definitive carboxylate efflux. Some of the results of the calculations are shown in Figures 9 and 10.

Influx of mobilized P as related to maximum citrate efflux of plants grown in a Ferralsol by (a) rye grass, (b) white clover and (c) red clover. (Modified from Gerke [24]).

Influx of mobilized P as related to citrate efflux of plants grown in a humic Podzol by (a) rye grass, (b) white clover and (c) red clover. (Modified from Gerke [24]).

For the three plant species such as rye grass, white clover and red clover, the maximum citrate efflux was used in the calculations (from Figures 2, 4, and 6). For the accumulation of citrate in soil, we assumed two strongly differing values in order to include a possible range of accumulation (see in detail Gerke [24]).

In none of the soils at either citrate accumulation level did the maximum citrate efflux of rye grass have any effect on the acquisition of P. The high overall citrate efflux of P-deficient red clover strongly increased the influx of mobilized P over the required level in all cases. White clover with a medium citrate efflux strongly increased the P influx of mobilized P in a soil with humic-Al(Fe)-P complexes as dominant P fraction. Compared to soils with mainly Al(Fe)-oxide-P complexes, humic-associated P is much easier to mobilize by carboxylates [46, 58].

The results shown in Figures 9 and 10 show that citrate excretion by P-deficient roots is an exceptional efficient way to improve P acquisition in P-fixing soils.

In their review on P efficiency, Richardson et al. [44] presented a separate chapter titled: “Can the release of organic anions from roots mobilize phosphorus?”

In this chapter, Richardson et al. [44] related [5–50 μmol citrate/g rhizosphere soil] to 1–10 [mM] citrate in the soil solution and then stated that 1 [mM] citrate or more is effective for P mobilization in some soils. This view on the rhizosphere chemistry of carboxylates and phosphate is misleading for at least two reasons.

First, the buffering of carboxylates in soil is a strongly varying soil parameter and cannot be generalized to a relation of 1–10 [mM] citrate versus 5–50 [μmol citrate/g soil], suggesting this as the general range of citrate buffering in all soils. Gerke [17, 24] showed for a strongly anion-fixing Ferralsol, that citrate concentration in the soil solution of less than 10 μM corresponds to more than 60 [μmol citrate/g soil] at the soil solid phase suggesting a much wider range of citrate buffering.

Second, it is a misleading view that carboxylates in the soil solution are responsible for the mobilization of P. The initial or essential step in P mobilization is the adsorption of the carboxylates to the soil solid phase where the carboxylate-mediated P desorption or dissolution of P-sorbing surfaces is initiated. In this context, simultaneous acidification and carboxylate excretion may increase the dissolution of P-sorbing sites more efficient than carboxylate excretion alone [21].

Finally, the role of root-derived carboxylates on the acquisition of P esters should be considered. This topic has been reviewed by Gerke [20]. In general, phosphate monoesters may accumulate in soils among which higher phosphorylated inositol phosphates account for the dominant proportion of ester-P in many soils [20].

Worldwide, more than 51 millions of tons of phytate (myoinositol hexakisphosphate) are annually produced in crops, seeds and fruits, which is equivalent to about 66% of the P annually applied to agricultural land [62]. Higher phosphorylated inositol phosphates are strongly bound to the soil solid phase often much stronger than the orthophosphate anion [20, 63]. The initial step of P acquisition from inositol phosphates is its mobilization.

Adams and Pate [64] showed that in soil, white lupin but not narrow leaf lupin can acquire P from phytate. White lupin forms root clusters with extensive citrate excretion, but narrow leaf lupin forms no root clusters [27].

The mobilization by carboxylates is the rate limiting step in acquisition of P from phytate and similar molecules and not the reduced activity of phytases. For a detailed discussion, see Gerke [20].

The partly contrasting results concerning the role of root-released carboxylates on P acquisition by higher plants are mainly due to deficits in the concepts of research and experimental methods.

Carboxylates will affect the soil P solubility after adsorption to the soil solid phase and not dissolved in the soil solution. It is a misconception to consider exclusively the carboxylate concentration in the rhizosphere soil solution and not the carboxylate concentration in the soil solid phase.

The determination of carboxylate bound to the soil solid phase is often ignored or is determined by deficient methods. Often, weak extractants such as dilute acids or dilute salt solutions are used, which extract a very low proportion of rhizosphere soil-bound carboxylates.

Considering the range of carboxylate efflux of P-deficient plants, especially cluster root forming plants such as white and yellow lupin, and species such as red clover, alfalfa, sugar beet and spinach may strongly mobilize the soil P and acquire the mobilized P.

Citrate and, to some extent, oxalate are the anions, which are most efficient with respect to P mobilization.

The most important organic P forms in soil, higher phosphorylated inositol phosphates are strongly bound to the soil solid phase and can be mobilized by carboxylates similar to the orthophosphate anion.

The quantitative effect of carboxylate excretion on the acquisition of soil P by higher plants requires an integrative concept, including all relevant soil and plant parameters. Such a framework may be a mathematical model based on experimentally determined parameters.

Individuals with mental impairment are struggling not only with the problems caused by their illnesses but also with the stigmatizing attitudes and behaviors of the society; even for this reason, stigmatization is often referred to as “second disease” [1]. When the stigmatizing attitude of the society is accepted and internalized as it is by the stigmatized individual, the problems in the individual’s life are increasing exponentially [2]. Among these problems, individuals with mental impairment are exposed to unfair behavior in the criminal justice system [3], restrictions on social facilities [4, 5, 6, 7], and most importantly, avoidance of treatment seeking behaviors and reduced quality of life [8, 9, 10]. In addition, it is suggested that the stigmatization not only affects the lives of the members of the family and their immediate surroundings but also the quality of life [11, 12]. One of the psychiatric disorders that are exposed to such stigmatizing attitudes and behaviors is obsessive compulsive disorder (OCD) although the stigmatization effect on the individuals who have received the diagnosis of schizophrenic disorder in the first and most recent years is discussed. OCD is a chronic mental disorder that negatively affects the quality of life and social, academic, and occupational functioning of individuals and families with this disorder [13]. Obsessions and compulsions experienced by an individual with OCD diagnosis, especially the distress experienced by them, cause the individual to be more isolated from the society. Moreover, it is stated that the quality of life is affected at a similar level to the diagnosis of schizophrenic disorder in OCD diagnosis [14]. In this chapter, it was aimed to explain the effect of the stigmatization in OCD.

The problems brought by individual and familial problems with a psychiatric diagnosis already have a very negative effect. In addition, individuals with mental disorders are exclusively excluded from society because of the reactions they are likely to exhibit and possibly display, as well as other people’s feelings, thoughts, and behaviors, with causal attributions, as seen in people with certain characteristics; rather than seeking treatment, they can choose to hide their problems at home and live a relatively isolated life. This, in turn, reduces the likelihood that many people with a diagnosis of being diagnosed have the potential to get treatment and solve their problems; this situation leads to many types of loss in terms of individual and society. For this reason, reducing the stigmatizing attitudes and behaviors in the society is at least as important as the treatment. In recent years, it appears that the number and nature of initiatives undertaken to reduce the stigmatization of mental disorders has increased significantly [15].

Stigma is defined as a characteristic or disorder that separates the individual from “normal” people in society and marks them as “unacceptable.” Stigma is defined by the World Health Organization [WHO] as “a sign of embarrassment, embarrassment, or rejection that has been excluded from rejection, discrimination and participation in different areas of the society.” [16]. The stigmatization process involves the identification of the separating state and then the step of disqualification of the individual [17]. The purpose of the stamp is to separate and exclude the individual from society [18]. Stigma means “scar, trail, sign,” but today, it is mostly used as “black spot.” The stamp is considered a symptom of a situation that is to be embarrassed for a person or a group or an unusual, unacceptable sign [18]. Stigmatizing is the individual’s mental or physical disability, his race, drug addiction, or any illness that is considered bad by the society. The individual is stained, flawed, and reduced to the eye of others. This causes the stigmatized individuals to fear the society and isolate itself from society [19] (Figure 1).

Problematic stigma cycle.

Stigma was originally used by the Ancient Greeks and symbolizes the physical signs that one has unusual and negative qualities in social or moral status. These signs are made by excavating the body or by tattooing, and evidence that a person carrying such a sign is a slave, a person who must be kept away like a criminal or a traitor. With the spread of Christianity, the term stigma is added. This ironic version refers to signs believed to have manifested itself in the form of bud-like sores on the skin, believed to be the physical signs of God’s mercy, as it is in the prophet Jesus, and thus believed to be sacred. The first person to take this issue in scientific terms is Goffman [20]. Goffman describes three distinct types of content that are quite different in content: (a) differences in personality (mental disorders, homosexuality, alcoholism, addiction, imprisonment, depersonalization, etc.), (b) various physical deformations (weak wills, extreme passions, perverted and rigid beliefs and immorality, stay, unemployment, suicide attempts) and (c) ethnological stamps (race, nation and religion). Stigmatization is defined as the perception of the individual as imperfect or obtrusive rather than normal; the stigmatized individual is less valued and these people are almost not perceived as human [20]. Stigmatizing is not a new phenomenon, but the traces are based on a rather old history. Many diseases arising from the existence of mankind have been perceived as catastrophic in the society and have caused the sufferers to suffer persecution. The plague that emerged in the 1300s was regarded as a punishment sent by God to sinful people, and people with plague were declared criminals. Individuals caught up in syphilis, which is quite common in Europe during the 15th century, have been cursed for centuries. Although such specimens now seem very out of date and old, similar misconceptions and beliefs still exist today. AIDS, previously known as homosexual disease, has been considered a divine punishment given to sinful people by God [21]. As a result, stigmatization has a history as old as human history, and many diseases have been subjected to stigmatization; it continues to stay.

There are several categories of stigmatization in our society, and beyond any description, stigmatization has been decisive for negative experiences at both macro and micro level. The three main types of Stigma include social stamping, self-stamping, and professional stamping (Figure 2). Social stigmatization is the most common.

Social and self-stigma.

According to Merriam Webster, social stigmatization indicates that (or dissatisfaction with) a person or group that is perceived by the other members of a society and serving to distinguish them is socially unapproved. Social theorists view such a stigma as particularly effective. A social group of the past is dependent on social information structures learned by most members [22, 23, 24]. In American society, there is a distinction between physical illness and mental illness and is based on the misperception that mental illness is a result of having a weak character or making a heretical choice [25, 26]. Social stigma against mental illness rests on this misperception [27]. This differentiation, which affects consumers, stakeholders, and providers, contributes to division and allows social stigmatization against mental illness, resulting in discrimination in diagnosis, treatment, and social perception. As a result of this social paradigm, people with symptoms are less likely to accept mental illness and receive appropriate mental health care [25, 26, 27].

Individuals are generally determined by their behavior, and unfortunately, behavioral problems associated with mental disorders result in poor self-esteem, limited participation, and reduced treatment. In addition, mental health results in avoidance of participation in services [22]. One of the difficulties of social stigmatization is that people who think that others perceive themselves differently perceive themselves differently. It is likely that the self may be stigmatized [23]. Considering that stigma is a social structure, culture significantly influences stigmatization. Culture expresses common behaviors, beliefs, values orientations, and symbols that affect a group of people’s own norms and practices. These sociocultural norms and practices also define the meaning, practice, and expression of the stigmatization in different populations [28, 29].

According to the literature, self-stigma is associated with perceived stigma. Persons suffering from mental illness will become self-imposed when they acknowledge that the people are prejudiced and discriminate against them because of their mental illness or illness. It tends to stigmatize itself, create feelings of shame, and lead to worse treatment and consequence [23, 30]. If a person who suffers from depression does not feel that it is worth being treated, the people with mental illness are less likely to have proven service and treatment requirements. A research has shown that negative stereotypes, such as danger or inadequacy, are often associated with mental illness and harm people living with the illness [23]. Therefore, this can be a possible reason behind the self-stigmatization.

Professional stigmatization refers to the fact that health care workers cause stigmatization of individual with mental disease and strengthen them. Healthcare workers do not want to be perceived as stigmatizing individual with mental illness suffering from mental illness. And for this reason, they can easily reject stigmatizing behaviors and beliefs. For this reason, it is important for professionals to become more aware of how the stigma can be predicted while working with individual with mental illnesses. Professional stigmatization may develop in a manner similar to the development of social stigmatization in the general population. Because a professional does not recognize the lack of appropriate treatment of a disabled client, he may be deprived of his rights and the individual with mental disease may become more vulnerable. This may lead them to terminate the treatment or to be treated elsewhere. Finally, professional stigmatization directed at the individual with mental disease or provider’s own illness creates an obstacle to the health of the individual by preventing appropriate treatment. It may also affect the acceptance of disorders by the healthcare worker’s own impersonal beliefs [24].

Common misconceptions about mental disorders can be described as follows:

mental disorders, heart disease, and cancer are not real disease;

people who need psychiatric care should be locked away at institutions;

a person with a mental disorder will never be normal;

those with mental disorders are dangerous;

individuals and young people with mental disorders do not suffer;

those with mental disorders can work at low job levels because they are not suitable for really important or responsible positions; and

people with mental disorders will become ill due to their crimes [31].

The causes of stigmatization for mental illness can be individual, social, and political. Especially, it is stated that the fear factor against the individual with mental illness is the biggest factor causing the stigmatization. These individuals with mental disease are considered dangerous by society; their balance completely corrupted, when they do not know what they are going to do; they damage their environment; and they have communication problems. Another cause and one of the most important reasons is that the mental illness is not perceived as a disease. Consequently, age, gender, education, occupation, marital status, social class, culture, religious beliefs, knowledge of disease, contact with mental illness, mental illness label, type of psychopathology, characteristics of individual with mental disease, and mass media are factors affecting mental illness stigmatization [32] (Figure 3).

How to decrease stigma in society.

Stigma has negative consequences for the individual in society. The stigma applied to individuals with mental disorders causes new difficulties in the individual’s treatment process. Some of the symptoms of mental illness such as reluctance, lack of motivation, low motivation, and loss of self-confidence lead individuals to withdraw to their own world. While individuals try to cope with the symptoms of illness, they also have to cope with the discriminatory behavior of being stigmatized by the society. Individuals who tend to withdraw from society because of their mental illness that tends to withdraw more out of society when exposed to stigma [1].

Stigma, in mental disorders, negatively affect their confidence in themselves, their participation in the treatment, their working lives, their use of social opportunities, their ability to defend their rights in criminal justice systems, and their participation in daily life activities [33]. Concern for exposure to stigmatization leads individuals and families with mental disorders to be hesitant about treatment. This causes them not to start treatment or to leave it at the start of treatment. Failure to provide regular treatment affects the individual with mental disease recovery process badly [8]. Stigma affects many areas in the daily life of individuals. One of these is a working life. For example, employers are reluctant to recruit because they see it as aggressive, dangerous, frightening, and unreliable. At the same time, they can use insulting words in business life and question their business performance. These thoughts and behaviors prevent individuals with mental disorders from participating in the working life. Moving away from working life leads to new problems such as not being able to be in society. This situation is causing their confidence to be shaken [34].

Stigma also prevents individual with mental disorders from using as much as they can from social facilities. As well as experiencing problems in having a satisfactory job, there is also a problem with the right to live in a home on safe and appropriate conditions. In a study by Willis and colleagues, individuals with long-term mental illnesses have experienced inadequate support, living in inadequate housing conditions and showing their lives on the streets [35]. Stigma also has negative consequences within the criminal justice system. According to a study by Lamp and Weinberger [36], it has been shown that 6–15% of individuals in prison in the country have severe mental disorders. In a study by Watson, Corrigan, and Ottati [37] investigating the stigmatizing attitude of police officers, it has been shown that an individual with mental impairment is perceived as more dangerous. At the same time, it was revealed that the information given during the query was not reliable. While being in the criminal proceedings is difficult enough even for individuals without mental disorders, this process is more difficult for individuals and families with mental disorders and negatively affects the healing process. The stigma negatively affects the quality of life’s the parents, spouses, siblings, caregivers, and people in close proximity to individuals with mental disorders. In a study by Phelan et al. [38], it was shown that families of people with mental disorders tend to conceal mental impairment from other people. Due to mental disorders in their families, they are exposed to social distance-setting behavior by the society. In summary, studies show that stigma is an obstacle for individuals with mental disorders to become active in daily life, participate in working life, and be in society.

Educational approaches to the dangers challenge false stereotypes about mental illness and change them to real knowledge. The training strategies included public service announcements, books, flyers, films, videos, Web pages, podcasts, virtual reality, and other audiovisual support [39].

A second strategy for reducing stigmatization is interpersonal communication with the members of the stigmatized group. People with mental illness have the potential to reduce the prejudice levels of the general population who meet and interact with people [40].

Social activism or protest is the third type of stigmatization change we have examined. Protest strategies emphasize the injustices of various stigma criminals for stigmatization and discrimination: “There is protest anecdotal evidence, such as embarrassing us all to continue the idea that people with mental illness cannot look after them, are big children.” Proposes that the protest can reduce harmful media representatives [41]. Psychiatry and medicine as a whole profession should develop effective methods against stigmatization of a group of mentally ill people and provide basic human rights. The relationship of psychiatry and the media, and especially the media, to psychiatry should be highly fair and professional, based on facts, not on sensation. Adequate and fair media coverage can significantly reduce the stigmatization of individual with mental disease. This can facilitate the functioning of the family and society. Therefore, changing attitudes will help people on medical care become more human and abandon negative attitudes that prevent us from becoming better and fairer [42].

In OCD, we witness obsession and compulsive rituals, usually both of them. Obsessions are repetitive and ongoing thoughts impulses or beliefs which are not as simple as worries of daily life, and individual tries to ignore them through coping mechanisms as they affect daily life and cause great anxiety. People with OCD realize that all of these thoughts only exist in their minds. Permanent impulses such as unwanted thoughts or beliefs that might hurt others, getting worked up over a turned on light or an open door, and suspicions over sexual impulses can be given as examples of obsession [38, 43].

Compulsions are repetitive behaviors and mental acts, as in washing hands consecutively, repeatedly checking the task at hand, praying, and counting. For the person to have rigid rules like counting to ten is a determining factor for the behavioral aspect. Individual would feel under pressure and “compulsed” to do. Compulsions have no relation with reality; their purpose is to decrease the stress and prevent bad things from happening in the person’s eye [44].

OCD leads to major difficulties in daily functioning and causes significant personality problems and mental problems when not treated. It is not surprising that the quality of life is affected by the problems encountered in functions and the nature of OCD. The social functions affecting quality of life in OCD are affected rather poorly than other mental diseases. Problems associated with intensive obsessions and compulsions affect social functions. Symptoms cause the individual to spend time with his or her family or work life. For this reason, the possibilities of positive social interaction and functional experience are reduced [45]. Anxiety may accompany obsessions and compulsions. Individuals feel themselves anxious and nervous. For this reason, the physical and social environment has an important effect on the emotional state of the individual. Both the environmental parameters and the symptoms affect each other. The anxiety that may arise from symptoms of the individual can be controlled by physical environment facilities and positive social support.

Stigma is a social force associated with people with many different health situations, feature, and social structures. Moreover, literature review shows that mental problems, sexuality, race, and STDs can also be regarded as related subjects [46]. Symptoms are not the only reason for the problems that people with psychiatric illnesses face in life. When problems these individuals live through are taken into account, stigma can be called a “second illness” [47, 48]. Individuals with psychiatric problems experience discriminatory behaviors and emotional acts in different forms. These labeling acts and situations create barriers against life opportunities for individuals. People who go through with stigmas might internalize these prejudices, in which case they start to believe that these beliefs are completely true and that creates some more barriers for them [49].

Stigma affects the people with OCD, and individuals might find themselves feeling under the weather or feel fear due to mental problem diagnosis, which can later affect the attitude toward the treatment and their motivation [47]. We see stigma as one of the many barriers we encounter on OCD treatment. Individuals with OCD go through a fear of stigma which can be described as a behavior to avoid the necessary help due to fear of a psychiatric diagnosis [50, 51] (Figure 4).

Obsessions and compulsions are related to anxiety and beliefs.

In society, general attitude toward people with mental issues is basically seen as “keeping away,” “observation,” and lastly isolation. Much of the mentioned compulsive rituals might seem unusual to the people unaware of the process individual with OCD go through. Society labels these individuals as people with strange behavior or people who act madly. The fact that labeling has started indicates that process goes to social stigma. If the person’s actions are found weird but can be tolerated, they are labeled as nervous people. Stigmatized people should be evaluated according to underlying reasons behind their illnesses and their belief in themselves. Rejection of a stigmatized person depends on etiology of the illness and its interpretation [52]. CD has great significance in lives of people with OCD and their families. As the people experience increasing obsessive and compulsive thoughts, they become socially isolated, and by time, their illness gets worse and they might need to be taken care of [53, 54]. Illnesses that are treated by psychiatrists are generally regarded as mental illnesses. This term traditionally used to describe serious mental problems, and it stigmatizes people with this problem via society and themselves. Many individuals with OCD refrain from receiving necessary support because of the risk of being stigmatized. They would often look for somatic explanations such as it being a dermatological problem in order to ignore the mental problem that they have [52]. Self-stigma is a term used in the case where the individual internalizes the negative approach he/she receives. Therefore, a person with OCB who internalizes the societal prejudices would feel a flaw in themselves and therefore would expect to be rejected by the society [1, 2]. Livingston and Boyd [46] show that self-stigma affects—very strongly and negatively—the psychosocial status such as empowerment and self-esteem as much as it affects individual’s psychiatric status.

Before obsessive and compulsive behaviors develop, individuals experience great trauma and intense stressful processes. Individuals’ responsibilities and the value they give to events determine the significance and importance of this process. Their fear of stigma causes to hide their experiences. This situation hampers help requests, including educators and health professionals. Symptoms of OCD cause time and energy loss in the individual’s life. This situation negatively affects the performance of the individuals in the activity areas that require social participation in particular. As a result, individuals isolate themselves from others [55]. Individuals with OCD often hide bullying and shame [56, 57]. They try to keep their obsessions and compulsions against future hurdles and that do not go to places that generate stress and anxiety. The presence of OCD can increase the risk of substance abuse and suicidal thoughts [58]. Attitudes and behaviors of peers are important for OCD children. As a result of negative attitudes and behaviors of peers, the possibility of exclusion of OCD children is very high. A study shows that 25% of participants are being excluded by their peers. Examples of behaviors such as kicking, hitting, rumor spreading, and social isolation are examples of peer attitudes [59].

As describe above, OCD, one of mental disorders, is also adversely affected by stigma. Due to the effects of OCD, both self-attitudes and others attitudes are negatively affected stigma that can cause problems in self-esteem, seeking treatment, benefiting from social opportunities, criminal justice system, and problems in family and friends’ relations. Families of individuals with OCD and close friends live difficult situations due to stigma. Self-stigma and the social stigma have a negative impact on their participation in daily life activities, their functionalities, their occupational lives, their productivity, and their social lives [33].

In individuals with OCD, emotions such as shame, guilt, and fear emerge during the first appearance of the disease. The first reaction is usually a tendency to reject. Individuals try to cope with the symptoms alone. They start to live with disease by trying to hide their symptoms. It is usually later that they perceive this as a disease. For this reason, it can be shown that they have no previous knowledge about the disease. The lack of insight causes them not seeking treatment, not getting help, and not doing research. They acknowledge that there is a trouble when it comes to coping with the symptoms, but the search for treatment with emotional factors such as shame, guilt, and fear is delayed again. OCD, like other mental disorders, is a psychiatric disorder that needs to be diagnosed and treated early. OCD diagnosis is usually delayed for such reasons. Individuals with OCD are resistant to interviewing health personnel and postpone treatment seeking. Treatment with the cause of hesitation in seeking treatment begins at a later stage of the disease. The delay in the onset of treatment affects the treatment process negatively in OCD, just as it is in other diseases. As well as having problems in seeking treatment with the cause of stigma, after the treatment starts, the treatment can also have problems with regular participation, continuity, and concluding the treatment. At the beginning of the treatment, the rate of cessation treatment in individuals is very high. Stigma slows down the process and causes them to have negative emotions. The treatment phase can be long-lasting, sometimes challenging and painful. While this process is difficult enough to cope with, the stigma makes this process even harder. The self-perception can be changed and his belief that he is a successful cure is shaken. The negative effect of stigmatization on patience and perseverance prevents the steady maintenance of treatment. These affect the prognosis of the disease negatively [3, 8].

Individuals with OCD experience feelings of shame, guilt, fear, and anxiety when they are diagnosed with the disease and prefer to fight alone in the treatment process. Fear of exposure to stigmatization prevents individuals from giving information about their illness to their relatives. In general, individuals tend to keep it confidential from the family and those close to them. This situation causes environmental support to fail. As with all other illnesses, it is important that environmental support is available to deal with the disease during the treatment process [60]. Concerns about accusations and exclusion by those who are close to the family in relation to other people cause problems and distances away from others [1, 61]. The tendency to keep the disease secret is caused by the inability to receive support from family members or close associates, and the prognosis of the disease is adversely affected. This is why getting help is important.

Studies show that violence and sexual obsessions are not shared in particular and that it is more difficult to seek help in this regard. Because of the feeling of embarrassment in these obsessions, it is delaying the search for treatment that cannot be shared with health personnel [61]. In another study, 738 adults were asked about pollution, symmetry, damage, and taboo obsessions. While symmetry obsessions were defined as OCD, subjects with taboo obsessions were exposed to stigma. Failure to have sufficient knowledge of OCD leads to the exposure of people with certain obsessions to the stigma, such as in this study [62].

Exposure to stigma, prejudiced and degrading attitudes, and discriminatory behavior of the community negatively affect the self-esteem of individuals. The stigma applied by the community is internalized by the individual and starts negative attitudes toward themselves. Individuals are self-stigmatizing and are beginning to label themselves. Once individuals begin to stamp themselves, they begin to diminish a sense of self-sufficiency. Later on, they do not have as much as self-confidence, self-esteem, and feeling of accomplishment, self-expression, and self-esteem. Self-esteem begins to be damaged, and the daily life of those who have problems people without self-esteem is negatively affected. Self-stigma influences their sense of success in their lives and their work life, their dissatisfaction, and their learning and development desires in the negative. They prefer to stay behind in business life, starting work, continuing, and finishing. But the problems of self-esteem and self-esteem of individuals are reducing the trust of employers. Self-stigma is also preventing participation in daily life activities. In everyday life, they are starting to refrain from carrying out activities such as communication, shopping, money management, and housekeeping. The problem that people live in self-esteem is causing their independent living skills to be negatively affected. Over time, they are becoming more dependent on their life. At the same time, they are also avoiding social activities that may be associated with other people. Their social activities such as participation in group activities, playing games, and being in contact with other people are being hurt. Self-stigma prevents the individual from making efforts on behalf of the formation of the social environment necessary to participate in social life. It leads to problems in the functionality of individuals [63, 64]. In sum, both the stigma created by other people and the stigma they apply to themselves are affecting negatively the quality of life of the individual with OCD.

Stigma also negatively affects the relationship of individuals with their parents. An individual may be exposed to stigma by his or her family. Having inadequate knowledge about OCD or having a false belief due to a mental illness leads the families to exclude them. They tend to reject the disease just like individuals when they first learn it. The families are starting to feel feelings such as shame, fear, anger, and guilt-like individual with OCD. This causes the individual with OCD tend to hide the signs of the disease and to hide themselves from other people. The treatment of the individual with OCD is adversely affected until the family begins to accept the disease. The fact that the parents do not see the symptoms of the disease as illness causes accusations of individuals with OCD [1, 3, 61]. During this period, the individual continues to internalize his self-labeling. The treatment of the individual is badly affected by his/her family’s and self-stigma of the individual with OCD stigma thus leads to the lack of family support and the poor prognosis of the treatment.

Stigma affects the relationship of individuals with OCD to their friends. Individuals tend to conceal their illness from time to time, even from friends. They try to hide the symptoms of their illness by their anxiety, anger, mockery, exclusion, and stigma exposure by their friends. For this reason, they prefer to stay away from their friends in this period, to be alone. The tendency to go away, the desire to be alone, and the closure causes the individual to be left alone with this disease. In the course of treatment, environmental support is reduced in this way. At school, at home, at work, and in social life, we spend time with friends almost everywhere. Friends have an important place in everyday life. At school, at home, at work, in cinema, in theater, at the café, in sports, in social activities, etc., getting away from friends who spend time together negatively affects daily life. Exposure to stigma after sharing your illness with friends also affects individual with OCD’s life negatively. The lack of knowledge and misunderstandings about OCD causes the symptoms of the illness to be perceived by the individual as deliberate behavior, and the individual’s friends may expose them to stigma in this case. It adversely affects the ability of the individual to perform daily life activities, productivity, occupational performance, and leisure activities. This causes the individual’s self-esteem to be impaired and the prognosis of the treatment to deteriorate [3, 62]. Persons who are friends with individuals with OCD are also exposed to stigma. People tend to think that they have the same behavior as individuals whose OCD is their friends. The personal characteristics and wrong evaluations attributed to the stamped individual are also attributed to the friends of these individuals. This situation also causes bad influence on friendship relations. The stigmatized individual’s friends lead him away from him, leaving him alone and weakening the friendship relationship. The daily lives, productions, social activities, and social support of the stamped individuals are negatively affected on the treatment process [3, 62].

OCD is a psychological disorder that affects daily life for individuals and their families. The general attitude of society to this disease is to stay away at first. Individuals with OCD start struggle in their daily lives because of indecisiveness, self-reliance, and disruptive behaviors. As individuals with OCD become more difficult to manage their daily lives, the individual with OCD’ families are starting to do it on their behalf. But sometimes families also begin not to deal with the tasks and activities of individual with OCD. For this reason, families feel stressed to take more responsibility for the daily life activities of the OCD individual [1]. Family members of individuals with mental disability are also exposed to stigmatization. Negative personal characteristics directed to the individual with OCD are also mirrored to the relatives of the individual with OCD. Families are shown as defective, guilty, and embarrassed. Recently, studies have been carried out on the stigma that the family is exposed to. Surveys reveal that they are worthless and humiliated because they are family members of the person with a mental disorder. The families exposed to stigma are under the pressure of the society. This increases the stress and anxiety of the family. Stress, anxiety, social stigma, can also cause mental ill effects on the family. Family stigmatization leads to a negative impact on both the relationship between the individual with OCD and the family as well as the relationship with society. They are moving away from society, starting to be alone and living in environmental constraints. Because of family stigma, family members are getting away from school, work, and outside, and their social participation is decreased [1, 65, 66].

The treatment process can be a lengthy and challenging process. It may become a situation that consumes the family and the individual with OCD. In the meantime, the family and the individual with OCD should be supported mentally well. Stigma can prevent with this support from family and individual with OCD. Negative attitudes toward the family influence the individual, giving the right support in the treatment process. Moreover, they are influenced negatively psychologically and socially. The inability of the family members to support as much as their ability to handle leads to slowing and prolonging the prognosis. At the same time, some of the destructive effects of the disease increase, causing negative attitudes about the process [1, 65, 66]. In summary, stigma on family of person with OCD; adversely affects family, person with OCD and their relationship.

Stigma not only affects adults but also youth and children. Since the incidence of OCD is lower in children, there is not much research done on them. Obsessions and compulsions seen in children affect their daily routines, family relationships, friendship relationships, and self-esteem. The self-esteem of children exposed to stigma by their friends is negatively affected. This causes many problems to emerge, in children, as in adults. Reduced self-esteem caused experiencing problems such as having trouble with going to school, not doing homework, not having friendship relationship, closing up, and difficulty to participate in the treatment.

Stigma also negatively affects children’s friendship relationship. The play takes an important place in the child’s life. Friends are needed to play games. Exposure to stigma among friends is causing them to move away. The game environment of a child who is away from friends is disappearing. Moreover, friendship relationship improves the level of stress of the child and loneliness. The exposure of the child to stigma causes nervous, angry, and anxious behaviors. The family of the child, whose stress level is increasing, is also negatively affected by this situation [67, 68].

The family that is exposed to the child’s stigma is also exposed to stigmatization. Family stigma causes family relations to be influenced, family members to be affected by the friendship relationship, and the level of family stress to be increased. The fact that the parents try to cope with these stress factors negatively affect their participation in the long treatment process of the child. Such problems caused by stigma are adversely affecting the treatment process in children, as well as in adults. Because of stigma, diminished supportive mechanisms, increased stress, emotional impact of the child, and problem of participation in the game are problematic in the progress of the treatment process [69].

In OCD management, medical perspective is dominant in general sense [70, 71]. However, OCD people continue their lives in society beyond medical drug treatment. Stigma is often referred to as secondary disease [48]. For this reason, it is important to have a biopsychosocial approach to OCD. Occupational therapists use the biopsychosocial and holistic approach for clients. In the following sections, individuals with OCD are referred to as client. For occupational therapy, it is important that the clients fulfill his roles, participation in occupations, and social participation and existence as an individual [72]. Occupational therapists do individual and/or community-based interventions to combat self-stigma, professional stigma, and social stigma that individuals are exposed to. Interventions to be conducted to client centered can be classified as promotion self-awareness, coping strategies, and encouragement. Interventions for social and professional stigma can be classified as occupational justice, community-based rehabilitation, education, and support groups.

“Self-stigma interventions can be classified promotion self-awareness, coping strategies and encouragement.”

In mental illness, individuals may not be aware of self-stigmatization. Because of wrong beliefs or thoughts about themselves, they may have difficulty in performing their roles and participating in their daily activities. For this reason, it is important to increase insight and to create individual awareness in reducing stigmatization. Occupational therapists can use cognitive behavioral therapy, psychoeducation, and also photovoice methods to help clients write and express their thoughts and behaviors who have difficulty in verbally expressing in order to provide individual awareness; thus, contributing to the client’s occupational identity and avoiding self-stigmatization.

Cognitive behavioral therapy involves changing individuals’ misconceptions with the right thinking. In this regard, it is accepted as a direct and permanent method. CBT, which is used in combination with medical treatment in many mental disorders, is highly effective. CBT, the most commonly used method of treating person with OCD, also has a significant role in reducing self-stigmatization [73, 74]. This method, which is widely used in OCD seen in children, helps to prevent the self-stigma that the individual applies to himself [75, 76]. CBT can be done individually or in groups [77]. Reaching of cognitive behavioral treatment is difficult because of the lack of specialized therapists in the field of reaching. Occupational therapists can specialize in this area to help OCD individuals overcome self-regulation. In addition, CBT is cost effective and accessible via the Internet [78].

One of the most important causes of self-stigmatization is having missing or incorrect information about the disease. Also, diagnosis can lead to labeling in individuals. Psychoeducation is one of the most effective and widely used method as CBT. Even brief information reduces the violence and social distance applied to the individual with OCD. The aim of this pyschoeducation is to give information about the individual’s illnesses, to reduce the self-labeling, and to raise the inner awareness of the client. In the context of ideal psychoeducation; medical, psychological, and sociological information about the disease should be included, information about treatment and process should be given, strategies for coping should be explained, and practical training should be done. In addition to these contexts, stories of individuals on similar conditions may increase the effectiveness of education. Occupational therapists can provide these trainings in community mental health centers, hospitals, OCD associations, or individuals with OCD who consultate to them [79].

Photovoice methods used for clients are actively involved in reflecting their lives through photography/draw picture and group work. Photovoice methods enable the individual to increase his/her inner awareness and understand the conditions of the disease and the obstacle [80]. Very few studies have focused on photovoice methods to prevent stigmatization and participatory approaches [81]. Nonetheless, the photovoice methods can be used to understand the paradoxical relationship between social stigma and ethical values. Kawa model developed by Iwama is a photovoice occupational therapy model. This model enables the individual to demonstrate a direct relationship with culture [82]. The client describes the situations in which the individual perceives their own life as difficulty or opportunity in his Kawa drawings. For this reason, in occupational therapy, Kawa River model can be used as an evaluation and intervention in providing stigma awareness. Bavaro has used the Model of Human Occupation [MOHO] to deeply understand the client with OCD. He stated that habits, rituals, environment, and an occupational therapy model can be used for evaluation and intervention of an individual’s occupational identity and performance [83]. With the MOHO model, occupational therapist can help to client to reconstruct his own occupational identity and find the source of inner motivation.

Also, Garland noted that in his study, animal-assisted therapy promotes family and individual communication, contributes to participation, and reduces stigmatization of the disease due to this signification and normalization [84]. Occupational therapist can use purposeful occupations such as animal-assisted approaches to increase social participation of the client and to facilitate social relationships.

Obsessions and compulsions and related maladaptive behaviors are the most common causes for individuals to social and self-stigma. Management of obsessions and compulsions are thought to diminish the problems encountered in social participation. Occupational therapists play a pivotal role in teaching different coping strategies and in providing effective use of these coping strategies in different environments and conditions with motor learning principles. Coping strategies can be classified relaxation techniques, body awareness, time management, and desensitization.

Relaxation techniques, which have 35.9% of the strategies used in OCD individuals, are frequently used in the management of anxiety disorders resulting in obsessions and compulsions [85, 86]. Relaxation techniques have been reported to cause somatic and cognitive components to relapse in obsessive compulsive disorders [87]. However, there is still a need for more study for OCD. Relaxation techniques control the repetitive rituals of individuals in their participation and therefore suggest that they can be protected from stigma. Occupational therapist specializing in body–mind awareness and relaxation techniques is needed. By promoting mind and body integration with the biopsychosocial approach, increase in body awareness is thought to have a positive effect on clients’ own thoughts.

Time is an important concept in the management of obsessions and compulsions seen in OCD. Participation of daily activities or social activities needs requirements for performance patterns. In occupational therapy, performance patterns define roles, habits, and routines. Beyond these performance patterns, there is also requirement for time management. Occupational therapists conduct an activity analysis to reveal the personal, environmental, and activity demands that activities require. The division of activities into tasks, followed by these steps, allows the regulation of the rituals of clients with OCD. However, occupational therapists teach OCD individuals time management techniques.

Sensory processing disorders in childhood may lead to excessive ritual behaviors. Children with tactile hypersensitivity were found to have an OC tendency later in life, and oral and tactile hypersensitivity in adults were associated with obsessions and compulsions. Studies of OCD on sensory processing both in childhood and on adult individuals show that desensitization techniques are effective on obsessions and compulsions [88, 89, 90]. In occupational therapy, sensory integration therapy and desensitization techniques in children and adults and the environment they live in have an important role in enabling individuals to cope with symptoms, fulfill their roles, and interact with the environment. These methods are thought to reduce stigmatization.

Individuals with OCD are also stigmatizing in their treatment seeking or avoiding treatment seeking because they are stigmatizing [91, 92]. Within this paradox, clients’ attainment of treatment and social inclusion are affected [30]. Occupational therapists should encourage individuals to participate in activities and manage health [72]. Encouraging clients with OCD is an important intervention to remove the negative consequences of the stigma.

For social and professional stigma, occupational therapy interventions can be categorized as providing occupational justice, community-based rehabilitation, education and support groups.

The concept of occupational justice argues that individuals have activity capacities, needs, and routines in their environments and have the right to use these capacities to maintain their lives and social participation and empowerment social inclusion [93, 94]. Stigma inhibits social inclusion in OCD individuals [47]. In occupational justice framework; occupational balance and occupational deprivation terms have been used. Occupational deprivation refers to the deprivation of the purposeful occupations the clients is doing due to social factors over time; the occupational alienation refers to estrangement, loss control, and sense of isolation due to social or self-conditions, while the clients fulfill their occupations and roles, and the occupational imbalance, in which there is an imbalance between the occupations required by the roles and the time allocated. Occupational deprivation and occupational alienation are inevitable for OCD due to stigma. The stigma in OCD needs to be considered in the context of occupational science.

Community-based psychiatric rehabilitation aims to provide rehabilitation services and sustainable services within the society and culture in which the individual lives. Studies about people with OCD and society can be effective in changing the cultural history of stigmatization. Projects supported by volunteers can also influence the cultural sub-structure of the stigma [95]. Occupational therapists can conduct community-based rehabilitation work and contribute to the social consensus of clients [96]. Community-based rehabilitation practice with an occupational justice conception that will provide social participation and reduce stigma is among the interventions occupational therapists will have [97]. Community participation, social inclusion, and occupational engagement are highly important occupational therapy interventions for reducing stigma and discrimination [98].

Occupational therapists visit the home where the client lives and make the home assessments. OT can provide OCD management and can make appropriate house arrangements for the client. The family and/or caregiver are informed. For school-aged OCD clients, OTs can visit the school, be informed by interviewing their peers and their teachers and if necessary, make appropriate environmental adjustments to the client. Informing adults and making workplace visits and environmental adaptations for clients with OCD have an important place in interventions that can reduce stigmatization.

Anti-stigma or reducing stigmatization interventions focused on the people with OCD and their families, health professionals, the general public, pupils and teachers, and health professionals. Education about OCD and misbeliefs is the primary aim of most campaigns, followed by the empowerment of people OCD and the prevention of impact of stigmatization [99, 100]. Occupational therapists have an advocacy role to promote social awareness and support the social integration of clients [72]. For OCD, occupational therapists can make these campaigns at a social level, and they can argue with politicians for legal regulations. It is among the responsibilities of occupational therapists to defend the rights of clients and to ensure the participation of clients with OCD in this way.

The media, however, play an important role in determining the attitudes of individuals toward perceptions and stigma and have a growing voice [101]. TV programs and publications have been reported to have positive effects on stigma [102]. A study on media reported that the Monk character, an individual with OCD, reduced stigma against OCD [60]. In the technology world, there are many people who reach through social media and individuals can be encouraged to tell their stories by digital storytelling methods. Thus, stigmatization can be decreased by increasing social awareness [103].

It has been noted that individuals with OCD have avoided treatment seeking because of the stigma they have seen most from their families. More stigma is reported to be applied especially in socio-demographic lower income families [104]. Also, family members living with the patient (such as parents, partners, children and siblings) are involved in daily rituals and undergoing social stigmatization. For this reason, families may encounter inequalities in occupational role performing. It is possible for OCD individuals to have access to treatment and to support their social integration and to provide social inclusion for the OCD individual’s family members. The biggest profit from the support groups could have individuals with high levels of self-stigmatization and poor social networks. Such groups might be focused on stigmatization (and thus indirectly on building self-esteem). The biggest profits from the support groups were the high levels of self-stigmatization and poor social networks. Educational activities are of great importance as such groups might be focused on stigmatization (and thus indirectly on building self-esteem), adaptive coping strategies to deal with daily hassles and interpersonal conflicts, and adopting supportive behaviors. These trainings can be made for health professionals for professional stigma, for children and adolescents with OCD [105], or for general public [100].

Taking social support from family and peers is the way to reduce the social stigma that families are going through. In many countries, support groups have been established for OCD individuals and their families. Bringing together individuals who live in similar conditions allows a group to become less isolated from society [106]. Children learn from their peers. Child or adolescent peer groups are also important in the context of the participation of children [80]. Web-based systems can communicate with social media [103] or virtual-based systems can be effective. The direction of occupational therapists to social support groups and peer support groups is the occupational therapy interventions that promote social integration of clients and thus reduce stigma [79, 106].

The best approach to reduce stigma should be a holistic approach and community-based rehabilitation to control clients’ symptoms, to protect the clients’ occupational identity, to tackle the client and the living environment together, and to raise the awareness of the clients, family, and the community.

As a firm believer in the wider dissemination of knowledge, IntechOpen supports the OAI Metadata Harvesting Protocol (OAI-PMH Version 2.0).

The OAI-PMH (Open Archives Initiative Protocol for Metadata Harvesting) is a protocol used to collect metadata descriptions and to enable other archives to access our database. The Protocol has been developed by the Open Archives Initiative, thus setting interoperability standards in order to ease and promote the broader and more efficient dissemination of content within the scientific community.

We have implemented the Protocol which increases the number of readers of our publications. All material is more widely accessible with resulting benefits for scholars, researchers, students, libraries, universities and other academic institutions. Through this means of exposing metadata, IntechOpen enables citation indexes, scientific search engines, scholarly databases, and scientific literature collections to gather the metadata from our repository and make our publications available to a broader academic audience.

As a Data Provider, metadata for published book chapters and journal articles is available via our interface at the base URL: http://www.intechopen.com/oai/?.

REQUESTS

You can find out more about the Protocol by visiting the Open Archives website. For additional questions please contact us at info@intechopen.com.

DATABASES

Some databases, repositories and search engines that provide services based on metadata harvested using the OAI metadata harvesting protocol are:

BASE – Bielefeld Academic Search Engine

One of the world’s most powerful search engines, mostly for academic Open Access web resources.

WorldCat – OCLC

A search engine for online catalogs of publications from all over the world.

The OAI-PMH (Open Archives Initiative Protocol for Metadata Harvesting) is a protocol used to collect metadata descriptions and to enable other archives to access our database. The Protocol has been developed by the Open Archives Initiative, thus setting interoperability standards in order to ease and promote the broader and more efficient dissemination of content within the scientific community.

We have implemented the Protocol which increases the number of readers of our publications. All material is more widely accessible with resulting benefits for scholars, researchers, students, libraries, universities and other academic institutions. Through this means of exposing metadata, IntechOpen enables citation indexes, scientific search engines, scholarly databases, and scientific literature collections to gather the metadata from our repository and make our publications available to a broader academic audience.

As a Data Provider, metadata for published book chapters and journal articles is available via our interface at the base URL: http://www.intechopen.com/oai/?.

REQUESTS

You can find out more about the Protocol by visiting the Open Archives website. For additional questions please contact us at info@intechopen.com.

DATABASES

Some databases, repositories and search engines that provide services based on metadata harvested using the OAI metadata harvesting protocol are:

BASE – Bielefeld Academic Search Engine

One of the world’s most powerful search engines, mostly for academic Open Access web resources.

WorldCat – OCLC

A search engine for online catalogs of publications from all over the world.

Skip to Main Content

A not-for-profit organization, IEEE is the world’s largest technical professional organization dedicated to advancing technology for the benefit of humanity.© Copyright 2019 IEEE – All rights reserved. Use of this web site signifies your agreement to the terms and conditions.