**5. Stigma in obsessive compulsive disorder**

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 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

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

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

self-esteem as much as it affects individual's psychiatric status.

96 Anxiety Disorders - From Childhood to Adulthood

**5. Stigma in obsessive compulsive disorder**

attitudes [59].

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].

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

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the stamped individuals are negatively affected on the treatment process [3, 62].

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

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

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, selfexpression, 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].

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

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, selfexpression, 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

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

family support and the poor prognosis of the treatment.

people with certain obsessions to the stigma, such as in this study [62].

98 Anxiety Disorders - From Childhood to Adulthood

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 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

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"Self-stigma interventions can be classified promotion self-awareness, coping strategies and

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

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

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

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

rehabilitation, education, and support groups.

encouragement."

**6.1. Promotion self-awareness**

and avoiding self-stigmatization.

is cost effective and accessible via the Internet [78].

individuals with OCD who consultate to them [79].
