Family Affiliate Stigma and Patient Internalized/Anticipated Stigma in Bipolar Disorder: A Multicenter Dyadic Study

Stigma in bipolar disorder is commonly conceptualized as an individual-level experience, but it may also be embedded within family systems. Family members may develop affiliate stigma, and patient-relative stigma dimensions may co-occur within dyads. Dyadic studies assessing these dimensions concurrently remain limited.

This multicenter dyadic study examined the association between relatives 'affiliate/family stigma and patients' internalized/anticipated stigma in bipolar disorder, and explored associations between stigma-related dimensions and illness-burden indicators.

The sample comprised 184 adults with bipolar disorder in remission and one adult relative per patient, recruited from seven centers across Türkiye. Diagnoses were confirmed using the SCID-5-CV. Stigma was assessed using parallel patient and relative forms of the newly developed Turkish-language Patient-Relative Stigma Questionnaire for Bipolar Disorder (PRSQ-BD). Psychometric analyses included internal consistency, exploratory and confirmatory factor analyses, and discriminant-separability indices. Dyadic associations were examined using linear mixed-effects models with random intercepts for center. Lifetime episode count and bipolar episode-related hospitalizations were analyzed using negative binomial regression models.

Higher relatives' affiliate/family stigma was associated with higher patient internalized/anticipated stigma after adjustment for sociodemographic and clinical variables. Patients' public stigma beliefs showed a strong statistical association with internalized/anticipated stigma. Patient internalized/anticipated stigma was statistically associated with lifetime episode count and hospitalization count. In dyadic hospitalization models, relatives' internalized/anticipated stigma was also statistically associated with hospitalization count.

These exploratory findings indicate that patient and relative stigma-related dimensions are associated within dyads and are statistically related to illness-burden indicators. Given the preliminary psychometric status of the PRSQ-BD and the cross-sectional design, findings should be interpreted as dyadic associations among theoretically specified mean-item indices, not as evidence of validated mechanisms, temporal pathways, or causal effects.