Differences in views of schizophrenia during medical education: a comparative study of 1st versus 5th–6th year Italian medical students

ORIGINAL PAPER

Differences in views of schizophrenia during medical education:a comparative study of 1st versus 5th–6th year Italian medicalstudents

Lorenza Magliano • John Read • Alessandra Sagliocchi •

Melania Patalano • Antonio D’Ambrosio •

Nicoletta Oliviero

Received: 23 February 2012 / Accepted: 8 October 2012

� Springer-Verlag Berlin Heidelberg 2012

Abstract

Purpose This study explored medical students’ causal

explanations and views of schizophrenia, and whether they

changed during medical education.

Method The survey was carried out on medical students

of the Second University of Naples, Italy, who attended

their first-year and their fifth- or sixth-year of lessons. The

381 who accepted were asked to read a case-vignette

describing a person who met the ICD-10 criteria for

schizophrenia and then fill in the Opinions on mental ill-

ness Questionnaire.

Results The most frequently cited causes were psycho-

logical traumas (60 %) and stress (56 %), followed by mis-

use of street drugs (47 %), and heredity (42 %). 28 % of

students stated that persons with the disorder could be well

again, and 28 % that they were unpredictable. Labeling the

case as ‘‘schizophrenia’’ and naming heredity among the

causes were associated with pessimism about recovery and

higher perception of social distance. First-year students more

frequently reported psychological traumas among the causes

(76 vs. 45 %), and less frequently heredity (35 vs. 81 %)

and stress (42 vs. 69 %), and they perceived less social dis-

tance from the ‘‘schizophrenics’’ than fifth/sixth-year stu-

dents. In particular, 18 % percent of first-year versus 38 % of

fifth/sixth-year students believed that these persons were

kept at a distance by the other, and 45 versus 57 % felt

frightened by persons with the condition.

Conclusions These results indicate a need to include

education on stigma and recovery in schizophrenia in the

training of medical students.

Keywords Medical students � Beliefs � Schizophrenia �Causal factors � Comparative studies

Introduction

All over the world schizophrenia is one of the most stigma-

tized mental illnesses [2, 3, 59, 60, 66, 73, 74]. The public

often perceives persons with this disorder as unpredictable

and dangerous as well as affected by a chronic, incurable

illness [34, 45, 54]. These stereotypical views of schizo-

phrenia exclude persons with this diagnosis from social, and

work opportunities [2, 4, 14, 17, 65, 69, 77].

In recent times, in an attempt to facilitate the acceptance

of persons with this disorder, schizophrenia has been pre-

sented, in destigmatisation programmes, as ‘‘an illness like

any other’’ [43, 54, 59] within the framework of a bioge-

netic causal model [18, 38, 43]. Regrettably, this emphasis

on genetic inheritance and brain abnormalities, which are

unchangeable causal factors, has strengthened the public’s

belief of schizophrenia as a chronic illness, and has led to

an increment of prejudices and social distances towards

‘‘schizophrenics,’’ who are perceived as unable to control

their behaviors and as dangerous and unpredictable [55, 57,

58, 67]. For other authors [38], genetic inheritance is of

secondary importance for explaining the increase in stig-

matizing and distancing attitudes, reported in recent studies

[54, 59].

L. Magliano (&)

Department of Psychology, Second University of Naples,

Viale Ellittico 31, 81100 Caserta, Italy

e-mail: [email protected]

J. Read

Department of Psychology, University of Auckland,

Auckland, New Zealand

A. Sagliocchi � M. Patalano � A. D’Ambrosio � N. Oliviero

Faculty of Medicine, Second University of Naples, Naples, Italy

123

Soc Psychiatry Psychiatr Epidemiol

DOI 10.1007/s00127-012-0610-x

Prejudice and discrimination towards persons with

schizophrenia are not rare, even in medical services [1, 6,

38, 65, 68], causing diagnostic delays, and substandard care

[10, 16, 23, 33, 37, 39, 75]. In particular, it has been

reported that medical doctors tend to interpret physical

complaints reported by persons with schizophrenia as signs

of their mental illness, and to underestimate symptom

severity [37]. Persons with schizophrenia also stated that,

when hospitalized for physical problems, they are treated

with disrespect by professionals, are kept apart from the

other patients, and transferred to a psychiatric unit as soon

as possible [37]. Difficulties in communicating with men-

tally ill persons have been reported by health professionals

[39]. Communication difficulties, in turn, contribute to

poor physical health of these mentally ill persons.

As part of society, medical students are not immune to the

stigma towards persons with schizophrenia [7, 22, 25–27,

31, 36, 42, 49–51, 53, 70]. Furthermore as future doctors,

medical students constitute a target population for destig-

matizing interventions in health contexts [30, 32]. Findings

show that medical students share common stereotypes and

prejudices about this disorder with senior clinicians and the

general population. In particular, 71 to 85 % of medical

students believe that persons with schizophrenia are

unpredictable, and 26 to 78 % believe that they are dan-

gerous. Furthermore, 4 to 21 % of medical students stated

that schizophrenia is an incurable illness [11, 26, 42, 49–51].

Research has also found that using the diagnostic label of

schizophrenia is associated with a greater desire for social

distance from persons with this disorder among medical

students. Results from studies that explored students’ views

at different stages of their education show that students at

the pre-clinical stage tend to share with the public a psy-

chosocial causal model of schizophrenia, while students at

the later clinical stage mostly adhere to the biogenetic model

[7, 8]. Knowledge of diagnostic and therapeutic skills, and

psychiatric rotation showed limited or short-term effects on

students’ prejudices about ‘‘schizophrenics,’’ and on their

pessimism about their recovery, although they have been

found useful to improve students attitudes towards the

‘‘mentally ill’’ and their confidence with psychiatric drugs

[5, 22, 28, 61–63, 71]. A study carried out on second- and

sixth-year students from three Turkish faculties of Medicine

[7] found that final-year students had a higher ability to

identify schizophrenia in a case-vignette (86 vs. 12 %), and

a higher confidence level in drug treatments for the illness.

However, the percentage of students who believed that these

persons were dangerous increased from 26 % of the second-

year students to 39 % of the sixth-year students, and the

percentage that viewed schizophrenia as an incurable illness

increased from 12 to 32 %.

Regarding Italy, one of the countries with the longest

experience in community mental health care, while several

studies have documented attitudes towards ‘‘schizophren-

ics’’ in the general population and among mental health

professionals [45], there has been little research on atti-

tudes towards ‘‘schizophrenics’’ in non-psychiatric health

contexts [70]. In 2010, we conducted a survey on causal

explanations and views of schizophrenia in a sample of 194

medical students in their fifth- and sixth-year of studies at

the Faculty of Medicine of the Second University of

Naples, Italy [46]. Findings revealed that these students

most frequently cited heredity as the cause of schizophre-

nia, and that only 24 % of them stated that persons with

this diagnosis could be well again. Both labeling a case-

vignette as schizophrenia and naming heredity as the cause

were associated with pessimism about recovery, and with a

higher perception that others keep their distance from

persons with this diagnosis. The survey was subsequently

extended to students in their first-year of medical education

to verify findings on a larger sample and to explore whether

students’ causal models and views of schizophrenia chan-

ged during their medical education.

In this paper, we report data on causal explanations and

beliefs about schizophrenia of 187 medical students in their

first-year of medical studies and 194 in their fifth- or sixth-

year. The study aimed to test the following hypotheses:

(a) that causal explanations and diagnostic labeling influ-

enced students’ views of schizophrenia. We expected

that students who attributed the disorder to genetic

factors, and those who identified ‘‘schizophrenia’’ in a

case-vignette were more pessimistic about recovery,

were more likely to consider these patients as danger-

ous and unpredictable, and acknowledged a higher

level of social distance from these persons by others.

(b) that views of schizophrenia differ between students at

the pre-clinical and the clinical years of education.

We expected that students in their first-year of

medical education, compared to those in their fifth-

or sixth-year, assigned more relevance to psychoso-

cial factors in the development of schizophrenia, were

more optimistic about recovery, and were less likely

to believe that these persons were dangerous, unpre-

dictable, and kept at a distance by others.

Methods

Study design

The survey was carried out on students of the Faculty of

Medicine of the Second University of Naples, Italy, who

attended their first-year and their fifth- or sixth-year of les-

sons in the period of December 2010 and April–June 2010,

respectively. Student participation was on a voluntary basis.

In this country, Medicine is a six-year academic degree,


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including a three-year pre-clinical stage followed by a three-

year final clinical stage. Psychiatric training is provided at

the fifth-year and consists of clinical lessons (on clinical

characteristics of mental disorders, on their bio-psycho-

social treatments, and on Italian mental health care organi-

zation), tutorial clinical workshops, and attendance of lab-

oratories and clinical facilities at the Department of

Psychiatry of the University Hospital. Therefore, all fifth-

and sixth- year students who participated in this survey had

previously received their graduate training in psychiatry.

Consent was sought by providing written information on

the purposes and content of the survey to eligible participants.

Those who accepted were asked to read a case-vignette

describing a person who met the ICD-10 criteria for schizo-

phrenia (without stating the diagnosis) and to complete the

Opinions on mental illness Questionnaire (OQ, 45). Respon-

dents were asked to think about ‘‘people with problems like

those described in the case-vignette’’, while completing the

questionnaire (‘‘Appendix’’). Respondents’ age and gender

were collected by additional items. Confidentiality and pri-

vacy of the participants were ensured using an anonymous

questionnaire. In accordance with the nature of the study and

the academic rules of the Second University of Naples, the

study was authorized by the Head of the Faculty of Medicine

in agreement with the local Research Ethical Board.

Questionnaire description

The Opinions on mental illness Questionnaire (OQ, 45) is a

self-report tool exploring beliefs about (a) the causes of

schizophrenia; (b) the effectiveness of available treatments

and patients’ right to be informed; (c) the psychosocial

consequences of schizophrenia (that is, problems that

persons with schizophrenia may experience in family and

affective relationships, and in social and occupational

roles; social distance from and perception of dangerousness

and unpredictability of persons with the disorder).

Respondents’ beliefs about causes are explored by a mul-

tiple-choice item and two open questions on what are, in

their opinion, the most important, and the most frequent,

causes of the condition described in the case-vignette.

Beliefs about treatments and psychosocial consequences of

schizophrenia are rated on 3-point scales, from 1 = ‘‘not

true’’ to 3 = ‘‘completely true’’. The psychometric prop-

erties have been previously found to be satisfactory

(Cohen’s kappa coefficient ranging from 0.50 and 1 for

74 % of the items; Cronbach alpha coefficient of the

subscales ranging between 0.42 and 0.72). In this paper,

items on respondents’ opinions about the causes, the pos-

sibility for patients to be well again, and on unpredict-

ability, dangerousness, and perception of social distance (4

items) are reported. Items were analyzed separately.

Statistical analysis

Associations of causal explanations and diagnostic

labeling of schizophrenia with respondents’ beliefs about

(a) the possibility that persons with the case-vignette

condition could be well again; (b) the unpredictability of

such persons; (c) the dangerousness of such persons; and

(d) the extent to which others keep their distance from

such persons (four items), were explored by v2. The

same test was used to explore differences between first-

year and fifth/sixth-year students in causal explanations

and beliefs about a to d variables. Statistical significance

level was set at p \ 0.05. Analyses were performed by

SPSS 15.0.

Results

Descriptive results

Of the 419 medical students who were contacted, 38

(9 %) declined to participate, leaving a final sample of

381 students. 187 out of 381 (49 %) of participating

students were in their first-year of medical studies (mean

age 19.8 (sd 2.1) years, 48 % male), 101 students (26 %;

mean age 23.9 (sd 1.3) years, 41 % male) were at their

fifth-year, and 89 students (23 %; mean age 26.3 (sd 2.6)

years, 45 % male) were at their sixth-year of medical

studies. Fifth- and sixth-year students did not differ in

gender. Preliminary analyses did not reveal any statisti-

cally significant difference between fifth and sixth-year

students in identifying a case of ‘‘schizophrenia’’ in the

vignette (85 vs. 81 %), or in their views about schizo-

phrenia. Therefore, fifth- and sixth-year students were

grouped together (194 students, mean age 22.6 (sd 3.8)

years, 171 (45 %) male).

Psychological traumas were the most frequently cited

cause (60 %), followed by stress (56 %), misuse of street

drugs (47 %), and heredity (42 %) (Table 1). Of the 306

out of 381 students (80 %) who expressed their opinion

about the most important cause of the disorder, 35 % cited

heredity, 14 % psychological traumas, 11 % stress, and

8 % misuse of street drugs.

Twenty-eight percent of the students stated that persons

with the case-vignette disorder could be well again

(Table 2). Meanwhile, 5 % of respondents firmly believed

those persons with problems like those described in the

case-vignette were dangerous and 28 % felt that they were

unpredictable (Table 2). Fifty-one percent of respondents

were convinced that ‘‘others’’ were frightened by these

persons, and 28 % believed that others kept them at a

distance.


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Relationships of causal explanations with respondents’

views on recovery, dangerousness, unpredictability

and perception of social distance

Students who believed heredity is a cause stated less fre-

quently than students who did not believe this that persons

with the disorder could be well again (20 vs. 40 %,

v2 = 16.0, df 2, p \ 0.0001), and were more frequently

convinced that ‘‘schizophrenics’’ were kept at distance by

others (34 vs. 20 %, v2 = 9.4, df 2, p \ 0.01), and that

people do not know how to behave with them (56 vs. 38 %,

v2 = 12.0, df 2, p \ 0.01), and do not understand their

difficulties (57 vs. 36 %, v2 = 16.3, df 2, p \ 0.0001).

Students who mentioned use of drugs as a cause believed

that people do not understand the difficulties experienced

by persons with schizophrenia more frequently than stu-

dents who did not mention drugs as a cause (55 vs. 42 %,

v2 = 7.07, df 2, p \ 0.05).

Relationships of diagnostic labeling with respondents’

views on recovery, dangerousness, unpredictability

and perception of social distance

Two-hundred forty-seven (67 %) students labeled the case

as ‘‘schizophrenia’’. Compared to students who did not

label the case in this way, those who did so cited heredity

(74 vs. 28 %, v2 = 72.6, df 1, p \ 0.0001), and physical

illness in pregnancy or childhood (17 vs. 6 %, v2 = 7.5, df

1, p \ 0.01), more frequently. Furthermore those who

labeled cited psychological traumas (54 vs. 71 %,

v2 = 9.3, df 1, p \ 0.01) and family conflicts (27 vs. 48 %,

v2 = 17.1, df 1, p \ 0.0001) less frequently. Compared to

students who did not identify a case of schizophrenia in the

vignette, those who did so more frequently viewed heredity

or stress as the most important cause of the disorder (45 vs.

19 %, v2 = 19.9, df 1, p \ 0.0001; and 31 vs. 4 %,

v2 = 31.5, df 1, p \ 0.0001; 14 vs. 6 %, v2 = 4.2, df 1,

p \ 0.05), and less frequently reported psychological

traumas (9 vs. 23 %, v2 = 11.4, df 1, p \ 0.001).

Compared with students who did not identify schizo-

phrenia in the vignette, those who did were less frequently

convinced that these persons could be well again (21 vs.

44 %, v2 = 22.6, df 2, p \ 0.0001). Moreover, students

who labeled the condition as schizophrenia more

Table 1 Medical students’ causal explanations of the condition

reported in the case-vignette

Causes Total

sample

(N = 381)

1st year

sample

(N = 187)

5th–6th year

sample

(N = 194)

N % N % N %

Heredityc 222 42 65 35 157 81

Psychological traumasc 229 60 142 76 87 45

Stressc 212 56 79 42 133 69

Disillusionment in lovea 82 22 28 15 54 28

Physical illness in

pregnancy or childhood

51 13 20 11 31 16

Physical illness 37 10 19 10 18 9

Incorrect therapy 66 17 39 21 27 14

Misuse of alcohol 93 24 41 22 52 27

Misuse of street drugs 177 47 91 49 86 45

Frequenting bad company 13 3 5 3 8 4

Family conflicts 128 34 59 32 69 36

Magic, spirit possession 7 2 5 3 2 1

v2: a p \ .\ 0.01, b p \ 0.001, c p \ 0.0001

Table 2 Medical students’ views about recovery, dangerousness,

unpredictability and social distance towards persons with case-vign-

ette condition

Items Completely

true

Partially

true

Not

true

N % N % N %

Will be well again*

Total sample 102 28 243 68 13 4

1st year students 56 33 109 64 6 3

5th–6th year years students 46 24 134 72 7 4

Are dangerous*

Total sample 17 5 229 67 96 28



Suddenly act strangely*

Total sample 96 28 204 61 37 11



Are kept at a distance by others*,c

Total sample 101 28 197 55 60 17

1st year students 31 18 103 59 39 22


People do not know how to behave with*,b

Total sample 181 48 183 49 10 3



People do not understand the difficulties experienced by*,b

Total sample 180 49 178 48 11 3



People are frightened by*,a

Total sample 189 51 166 45 15 4



*persons with a condition like that described in the case-vignette

v2: ap \ . \ 0.05, bp \ 0.01, cp \ 0.0001


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frequently stated that the others kept persons with this

disorder at distance (33 vs. 20 %, v2 = 7.3, df 2, p \ 0.05),

do not know how to behave with them (53 vs. 39 %,

v2 = 8.5, df 2, p \ 0.01), do not understand their diffi-

culties (53 vs. 40 %, v2 = 8.8, df 2, p \ 0.012), and that

they are frighten by them (57 vs. 41 %, v2 = 7.7, df 2,

p \ 0.02).

Comparisons of 1st and 5th–6th year students in causal

explanations and views on recovery, unpredictability,

dangerousness and perception of social distance

The causes of the disorder most frequently reported by

first-year students were psychological traumas (76 %) and

misuse of street drugs (49 %), while the fifth/sixth-year

students most frequently cited causes to be heredity (81 %)

and stress (69 %).

Compared to fifth/sixth-year students, first-year students

more frequently reported psychological traumas among the

causes (v2 = 37.7, df 1, p \ 0.0001), and less frequently

heredity (v2 = 84.9, df 1, p \ 0.0001), stress (v2 = 26.9,

df 1, p \ 0.0001), and disillusionment in love (v2 = 9.5, df

1, p \ 0.01). In addition, psychological traumas were more

frequently cited as the most important cause by first-year

students (21 vs. 8 %, v2 = 11.2, df 1, p \ 0.001), whereas

heredity (16 vs. 52 %, v2 = 43.6, df 1, p \ 0.0001), or

stress (3 vs. 19 %, v2 = 19.1, df 1, p \ 0.0001) were more

frequently mentioned by the fifth–sixth year students. First-

year students labeled the vignette as ‘‘schizophrenia’’ less

frequently than the fifth/sixth-year ones [49 vs. 82 %,

v2 = 46.2, df 1, p \ 0.0001].

Beliefs about recovery, unpredictability, and danger-

ousness did not differ significantly between first-year and

fifth/sixth-year medical students (Table 2). In particular,

33 % of first-year respondents and 24 % of fifth/sixth-year

students firmly believed that persons with the case-vignette

disorder could be well again. 71 % of first-year respon-

dents and 73 % of fifth/sixth-year respondents believed,

totally or partially, that persons with problems like those

described in the case-vignette were dangerous, and 92 and

86 %, respectively, believed that they were unpredictable.

Students’ perception of social distance by others was

significantly lower among first-year respondents than

among fifth/sixth-year ones. In particular, 18 % of first-

year medical students versus 38 % of fifth/sixth-year stu-

dents believed that these persons were kept at a distance by

the others (v2 = 20.5, df 2, p \ 0.0001), 40 versus 56 %

believed that others did not know how to behave with these

persons (v2 = 9.9, df 2, p \ 0.01), 42 versus 56 %

believed that others did not understand their difficulties

(v2 = 10.8, df 2, p \ 0.01); and 45 versus 57 % felt

frightened by persons with this condition (v2 = 8.8, df 2,

p \ 0.012).

Discussion

This is the first study carried out in Italy that specifically

compared students’ views of schizophrenia in the first and

final years of their medical education. The findings of this

study highlight that medical students’ views of causes and

social distance from persons with schizophrenia signifi-

cantly vary over the course of their medical education, and

that there is a close relationship between adoption of a

biogenetic causal model and perception of social distance

and pessimism about recovery.

Although the study involved a large number of students

and had a high response rate, it had several limitations that

should be taken into account in the interpretation of its

results. First, the survey was conducted among students

from only one medical school in Italy, and the sample may

therefore not be representative of all medical students. In

addition, Second University of Naples is located in

Southern Italy, a geographical area where healthcare

resources are poorer and public prejudices towards men-

tally ill persons are higher than in Central and Northern

Italy [44]. Other limitations include the lack of a control

group of other common mental disorders such as depres-

sion, where the social acceptance is higher than that for

those with schizophrenia [3, 13, 52], and the fact that

students from other health disciplines, such as nursing and

psychology, were not involved [78]. Moreover, the fact that

the study did not assess attitudes in clinicians and academic

teachers prevents us from exploring their influence on

medical students’ beliefs [26, 36, 50]. Finally, since the

study was not a cohort one, it could not be ascertained

whether the first-year students were comparable to fifth–

sixth-year students on certain confounders, such as

respondents’ experience with ‘‘schizophrenics’’. Most of

these limitations will be specifically addressed in further

studies which are now at the planning stage.

With regards to the influence of causal explanations on

students’ attitudes, in line with findings from previous

research, students who reported heredity among the causes

were more pessimistic about possibility of patients to be

well again. Furthermore, students who mentioned biologi-

cal causes perceived a higher social distance kept from

these persons by the others [38, 54, 55, 78]. These results

confirm the findings of numerous previous studies that the

adoption of a biogenetic model of schizophrenia can

increase social exclusion of mentally ill persons [59], even

in health contexts [58, 60]. However, it is possible that

first-year students who endorsed this model are different

from fifth- to sixth-year ones, due to being exposed to

different experiences.

As found in previous studies [59], labeling the case as

‘‘schizophrenia’’ was associated with respondents’ greater

perceived distance from persons with this diagnosis. These


123

associations are probably related to a stigma-inducing

effect of the term ‘‘schizophrenia’’ by itself [47], which

may significantly contribute to discrimination experienced

by persons with this diagnosis, including in medical and

surgical contexts [41, 76].

Students’ causal explanations of schizophrenia are sig-

nificantly different at the end of their medical training from

their beliefs at the outset of their training. Compared to

first-year students, those in their fifth and sixth years

reported much more frequently heredity and stress and less

frequently psychological traumas among the causes of

schizophrenia. These findings suggest a shift in medical

students’ model of schizophrenia from a psychosocial to

bio-psychosocial one, over the course of their medical

education [7, 8, 71]. At their final stage of education, stu-

dents tend to adhere to a vulnerability-stress model of

schizophrenia, similar to that found in clinicians. This

model is different from that postulated by Zubin and Spring

[81]. These authors clearly stated that vulnerability could

be ‘‘acquired’’ as a result of early adverse life events.

However, fifth- and sixth-year students seem to refer to a

distorted model of stress-vulnerability, in which heredity

appears as the determinant causal factor—and the most

important one for 53 % of students—and stress as a generic

trigger [11, 57, 58]. This modified model, unbalanced in

favor of heredity, may significantly influence information

and treatments provided by clinicians to these patients [80].

In particular, if heredity is thought to be ‘‘true’’, this

unchangeable cause of schizophrenia may lead to the belief

that recovery is unlikely [60]. Furthermore, if stress is

perceived merely as a trigger factor, then there could be

little to do for these patients apart from controlling symp-

toms by drugs over their life span [56]. These views may

have a demoralizing effect on patients and their families

[57], thereby creating a self-fulfilling prophecy whereby

pessimism leads to decreased efforts to change.

Consistent with previous studies on medical students’

beliefs about recovery in schizophrenia [26, 42, 49–51],

28 % of students firmly believed that persons with this

diagnosis could be well again, and a further 68 % partially

believed that recovery was possible. Only a non-statisti-

cally significant decrement in students’ beliefs on recovery

was found between the two samples, findings less dis-

couraging than that reported by Ay [7], but still far from

long-term studies evidences that recovery is a realistic goal

for a large number of ‘‘schizophrenics’’ [9, 40, 79].

Five percent of respondents firmly believed that patients

with schizophrenia were dangerous. It is likely that this low

percentage, which is similar in the two samples, is related

to the case-vignette content, that refers to ICD-10 criteria

of schizophrenia and does not include violent behaviour.

However, it cannot be excluded that a firm agreement on

dangerousness has been perceived as ‘‘politically’’

incorrect by medical students [46], as also supported by a

percentage of 67 % of respondents who ‘‘partially’’ agreed

with it. This hypothesis is also supported by the higher

percentage of students who firmly felt these persons as

unpredictable, a feeling significantly related to danger-

ousness also in this sample (r = 0.24, p \ 0.0001).

Thirty-eight percent of students firmly believed that ‘‘the

others’’ kept at a distance persons with schizophrenia, and

56 % that ‘‘the others’’ do not know how to behave with

these persons. It is likely that students have projected in

‘‘others’’ their own difficulties in interacting with mentally

ill persons, a situation reported as present in more than

50 % of medical students in their final studies [35].

Respondents’ attribution of own social distance to other

people is also supported by correlations of perceived social

distance in others with perceptions of dangerousness and

unpredictability that we found in this sample (0.18,

p \ 0.001, 0.22, p \ 0.0001).

From the pre-clinical to the clinical period, a significant

increment in students’ perception of social distance by

‘‘others’’ was found. This could be due to several factors,

including (a) the rotation of fifth- and sixth-year students in

medical and surgical units where they observe and assim-

ilate clinicians’ attitudes and behaviours towards persons

with mental disorders [7, 36, 63, 68], (b) the organization

of academic departments of psychiatry in Italy, which do

not include necessarily all range of community facilities as

the local mental health departments. Consequently, medi-

cal students have the opportunity to be in contact with

patients with severe mental illness but rarely to be in

contact with those who live independently in the commu-

nity [20, 22], (c) students’ acknowledgment of prejudices

among users with physical problems towards persons

affected by mental illness. This condition may significantly

influence clinicians’ behaviours towards mentally ill per-

sons, working as a sort of ‘‘stereotype threat’’ [12, 34],

(d) cynicism of students close to their final degree towards

persons with mental illness, and the stigmatization of

psychiatry as a discipline that is ‘‘at risk’’ for professionals’

mental health and a poorly attracting career opportunity

[21, 24, 71], and (e) the increasing technicalization of

medical education and the attention paid to clinicians’

communication and empathic skills [64].

In order to change this situation, topics such as recovery

and stigma in schizophrenia, and exposure to rehabilitative

programs to users and families should be included in

medical education [12, 15, 19, 29, 30, 48, 56, 78, 80].

Furthermore, it could be useful to train students in the early

stages of their medical education on how to communicate

with persons with mental disorders when they have an

acute episode and on how to control their emotional reac-

tions to these persons. In our Faculty, for example, on the

basis of the findings of this survey, seminars about the


123

above-mentioned topics are held yearly. These seminars,

developed in collaboration with users who have recovered

from or are successfully living with the symptoms of

schizophrenia, specifically address topics such as clinical

and social recovery, the association of schizophrenia with

social danger and perception of unpredictability, and the

effects of media on stereotypes against ‘‘schizophrenics.’’

We hope that these ongoing seminars, whose outcome will

be reported in further papers, will improve the attitudes of

future doctors towards persons with schizophrenia, and

increase the probability that these patients will receive

the same medical treatments and respect as other patients

[66, 72].

Acknowledgments The authors thank: (a) the Professors of the

Faculty of Medicine of the Second University of Naples who facili-

tated the conduction of the study: A. Capuano, D. Cozzolino,

A. Crisci, A. Filippelli, G. Delrio, A. Perna, S. Perrotta, F. Rossi,

D. Ronca, M. Russo, N. Sannolo, A. Scotto di Tella;

(b) Prof. I. Levav, Research Unit, Mental Health Services of the

Israeli Ministry of Health for his valuable comments on the final draft

of this paper; (c) D. Celona, L. Guariniello, and S. Rega for their

contribution in the collection of the data; (d) the 381 participating

students for their active involvement in the survey.

‘‘Appendix’’

Case-vignette

Some people sometimes seem unable to distinguish

between things that really happen and are experienced by

other people, and things that happen only in their mind.

Sometimes, these people believe or say things that seem

bizarre or absurd to other people, or hear voices, smell

things, or see images that other people do not. Sometimes,

these people may have difficulty expressing their feelings

or behaving appropriately (for instance, they may cry in

response to a positive event, or may appear happy fol-

lowing an unpleasant one), or they may remain shut up in

their house for a long time, or talk very little or not at all.

They behave as if they lived in a world of their own,

apparently without interest in anything or anybody.

Sometimes they may have muddled thoughts, may invent

odd or incomprehensible words, may lose the thread of the

speech, or they may jump from one issue to another with

no apparent reason.

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Differences in views of schizophrenia during medical education: a comparative study of 1st versus 5th–6th year Italian medical students