See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/305699960

Factors Associated with Self-esteem in Patients with Chronic Schizophrenia

Article · January 2016

CITATIONS READS

2 493

1 author:

Sandhyarani Mohanty
Institute of Mental Health and Hospital, Agra
43 PUBLICATIONS   62 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Sandhyarani Mohanty on 28 July 2016.

The user has requested enhancement of the downloaded file.

Kumar, S. and Mohanty, S. (2016) Factors Associated with Self-esteem in Patients with
Chronic Schizophrenia. SIS Journal of Projective Psychology and Mental Health, 23, 56-60

Factors Associated with Self-esteem in Patients with Chronic Schizophrenia

Prof. Sudhir Kumar and Dr. Sandhyarani Mohanty.

Abstract

Self-esteem is an important component of psychological health. Self-esteem refers to an

individual’s sense of value or worth, or the extent to which a person appreciates, or likes
himself. Treatment failures, functional loss, demoralization and stigmatization may lower
self-esteem in patients with severe mental illnesses. Low levels of self-esteem have been
implicated as both a cause and a consequence of severe mental disorders. Low self-esteem
contributes in both the development of delusions and the maintenance of psychotic
symptoms. The present study aimed at exploring the self-esteem and its associated factors
in persons with chronic schizophrenia. This is a cross-sectional correlational study
conducted at Institute of Mental Health and Hospital, Agra. The sample consisted of 50
persons with chronic schizophrenia in the age range of 20-55 years. Rosenberg Self-esteem
Scale, PANSS and Schedule for Assessment of Insight (SAI) were administered on the
participants. The results revealed significant association of the level of insight, Current
functioning of the patient, positive symptoms, negative symptoms and general
psychopathology with the self-esteem.

Key Words: Self-esteem, Schizophrenia, Psychotic Symptoms.

Self esteem refers to an individual’s sense of value or worth, or the extent to which a
person appreciates, or likes himself (Taylor et al, 2000). It is often found to be
compromised among persons with mental illnesses (Van Dongen1996). Low self-esteem
is considered as a possible consequence and a possible cause of psychiatric symptoms
(Greenberg et. al.,1992; Karatzias et. al, 2007; Blairy et al. 2004). Link et al. (2001)
reported that stigmatization and self-stigmatization may lower self-esteem in persons with
mental illness. Previous researches also indicated that lowered self-esteem frequently
accompanies or became an etiological factor in many psychiatric conditions (Robson,
1998; Silverstone et al, 2003).

The risk of psychiatric disorders such as depression, eating disorders and substance
abuse increases due to low self-esteem (Silverstone & Salsali, 2003). Some studies
reported that low self-esteem has a key role in developing delusions (Bentall et. al, 2001;
Barrowclough et.al., 2003) and the maintenance of psychotic symptoms (Garety et. al.
2001). One study showed that the contents of patient's delusions were consistent with
patient's global self-esteem and suggested that low self-esteem accounted for the

1
persistence of delusions (Bowins & Shugar, 1998). Studies also reported significant
correlations between negative self-evaluation and a wider variety of positive symptoms i.e
hallucinations and delusions in schizophrenia (Barrowclough et. al. 2003). It has been
found that patients with a low level of self-esteem and more depressive symptoms had
more intense auditory hallucinations with a more negative content (Smith et. al., 2006).

The theory proposed by Crocker & Wolfe (2001) suggested that self esteem is a trait and
state measure and it varies based on the self-judgments and interpretation of the events
or circumstances, and its relevance to his or her contingencies of self-worth, as well as
social feed-back. Link et al (2001) found 24% of the people with schizophrenia scored
below the mid-score (reflecting low score and low self-esteem). Silverstone et al., (2003)
also found that patients with schizophrenia had intermediate levels of self-esteem.
Schizophrenic patients have significantly low self-esteem in comparison to other
psychiatric conditions and they are expected to have a compromised quality of life and
poor psychosocial functioning (Breeke et al., 2001; Gureje et al., 2004).

There are few studies to show correlation between self-esteem in people with
schizophrenia with any socio-demographic factors. In one study, female patients were
found to have higher self-esteem than their male counterpart (Sorgaard. et al, 2002).
Brekke et al (2001) studied executive functioning as a moderator of the relationship
between psychosocial functioning and the self-esteem. They found that patients with
impaired executive functioning displayed a positive and statistically significant association
between psychosocial functioning and self-esteem but those with intact executive
functioning showed negative association.

AIM

The study aims to determine the level of self-esteem and the factors that are associated
with the level of self-esteem in patients with schizophrenia.

Method

This is a cross-sectional correlational study conducted at Institute of Mental Health and

Hospital, Agra. The sample consisted of 50 persons with chronic schizophrenia. The
following inclusion and exclusion criteria were adopted while selecting the sample.

1. The age range of the patients were 20-55 years.

2. ICD-10 DCR criteria were followed for diagnosing the patients.
3. The minimum duration of illness were 2 years.
4. Patients with any comorbid condition and major physical and neurological
abnormalities were excluded from the study.
The following tools were individually administered on each subject by the research staff.

1. Rosenberg Self-Esteem Scale: The scale is a ten item Likert scale with items
answered on a four point scale – from strongly agree to strongly disagree. It
measures general feelings about own self. Higher scores indicate higher self-
esteem. The maximum score is 30.
2. Positive and Negative Syndrome Scale (PANSS): It is developed by Kay et al.
(1987). It is used for measuring symptom severity of patients with schizophrenia. It
measures positive symptoms, negative symptoms and general psychopathology.
7 point ratings are used for each symptom. Higher score reflects more
psychopathology.
3. Schedule for Assessment of insight (SAI): It is developed by David et al.
(1992). It is a three-item rating scale used to evaluate insight in psychotic illness.
It evaluates insight on three dimensions (a) Recognition of mental illness (b) the
ability to recognize abnormal mental events (c) Treatment compliance. Responses
are scored on a 0 to 2 scale. Higher score reflect better insight.

Results:

Table-1: Mean, S.D., t-values and Pearson Correlations with Self-esteem

Variables n Mean (S.D) t-value / Pearson r/ p value
Marital Status Unmarried 08 17.87 (3.27) t=.349 NS
Married 42 18.38 (3.83)
Socio-economic Status Low 11 19.09 (3.80) t=.431 NS
Middle 39 18.07 (3.72)
Domicile Rural 31 18.16 (3.91) t=.333 NS
Urban 19 18.52 (3.48)
Family H/O Psychiatric Yes 09 16.00 (3.39) t=2.11 p<.05
Illness
No 41 18.80 (3.64)
Working Status No 18 21.55 (2.81) t=6.11 p<.01
Yes 32 16.46 (2.82)

Age (in years) 38.02 (7.00) r=.04 NS

Education (in years) 7.66 (5.50) r=.128 NS
Duration of Illness (yrs) 8.02 (2.72) r=.132 NS
SAI Scores 7.24 (4.18) r= -.820 p<.01
PANSS Positive 16.28 (5.36) r=.886 P<.01
PANSS Negative 12.00 (5.09) r=.833 P<.01
PANSS General 33.38 (9.01) r=.768 P<.01
Table-1 reveals that there is no mean difference in self-esteem across following variables
– Marital Status, Socio-economic status and Domicile. However, significant mean
differences are observed in the patients having family h/o psychiatric illness and having
occupational involvement. Age, Education and Duration of illness do not have significant
correlation with self-esteem. GAF and Insight have significant negative association with
self-esteem whereas three forms of psychopathology have positive significant correlation
with self-esteem. The mean scores on Rosenberg Self-esteem Scale was 18.30 having
an S.D. of 3.72.

Discussion:

The results revealed a significant positive between three forms of psychopathology (a)
positive (b) negative (c) general vis-à-vis self-esteem. Apparently at a superficial level this
may appear to be contradictory to what is expected. But a thoughtful consideration would
depict a different picture. While schizophrenic patients are symptomatic they have a
distorted view of themselves. Their views of themselves do not correspond to the reality.
Under the influence of psychopathology they may tend to consider themselves high
yielding a statistically positive relationship with the self-esteem. As the severity of
psychopathology increases their ratings on the measure of psychopathology too
increases. Upon resolution of the symptoms they come into contact with reality and
revaluate themselves more or less in pursuance of the reality which is reflected in the
lowered self-esteem. They become aware of their limitations, psychopathology and the
disturbances that caused in their family, occupational and social life. The decreased level
of psychopathology is associated with a critical and lowered view of oneself. This
scenario of decreased psychopathology coupled with lowered self-esteem may partly
explain the depressive pathology seen in post-psychotic episodes.

There is an internal consistency in the results of self-esteem and psychopathology as

obtained in this study. Upon resolution of the symptoms the patients tend to show
improvements in their global functioning as well as their insight will also show therapeutic
gains. The higher levels of insight again pose a risk of critical view of one’s functioning
and behavioural disturbances during the active phase of the pathology. This causes a toll
on their sense of self. Hence, the gain in insight is associated with decreased self-
esteem. This is reflected in the significant negative correlation between scores of
Schedule of Assessment of Insight and self-esteem measure.

The implications of it are far reaching. The obvious goals of treatment are the resolution
of psychopathology and improvements in the level of insight. But these improvements are
associated with lowered self-esteem which is likely to have a link with depressive features
in the schizophrenic patients. This situation warrants the need for psychosocial
intervention with the patients in order to manage their self-esteem and also to manage
resulting depression.

Apart from the risk of depression, the negative self-esteem is also associated with very
high risk of relapse in schizophrenic patients (Holding et al. 2013). Erickson & Lysaker
(2012) while investigating the role of insight and self-esteem in symptoms of
schizophrenia concluded that self-esteem is significantly associated with
psychopathology in schizophrenia.

The lowered self-esteem may be an outcome of a number of variables like stigma and
discrimination associated with mental illness, impaired psychosocial functioning due to
the illness, early childhood experiences, premorbid personality and the like. In the present
study, it was found that the patients who have a family h/o psychiatric illness have
significantly lower self-esteem as compared to the patients without such history. The
patients who were engaged in gainful occupations also showed lowered self-esteem than
the non-working persons. This again may be a reflection of the compromised capacities
to carry out the job related responsibilities and a stigmatizing attitude.

We need to look into various dimensions of self-esteem as this is a significant variable

that is implicated in the mental illness at both pre morbid and post morbid level. The
lowered sense of self-esteem makes a person more vulnerable to the mental illness and
the onset of illness further cause injury to the self-esteem. While taking up self-esteem as
the target of intervention, we need to work out comprehensively so that the patients come
up with a reasonable view of oneself and deal effectively with the issues that are likely to
hurt their sense of self.

Conclusion:

Self-esteem is significantly associated with psychopathology, insight and other variables.

The improvement in psychopathology and insight has potentials for compromising the
self-esteem in the patients with schizophrenia. The lowered self-esteem can increase the
probability of relapse and depression. This aspect of the being need be addressed
explicitly in the patients particularly when they are recovering from active phase of their
psychopathology. Future research should consider delineating various factors that are
antecedent to the decreased self-esteem in the persons with schizophrenia.

References

Barrowclough, C., Tarrier, N., Humphreys, L., Ward, J., Gregg, L. & Andrews, B.(2003) Self-
esteem in schizophrenia: relationships between self-evaluation, family attitudes, and
symptomatology. Journal of Abnormal Psychology, 112,92-99.
Bentall, R.P., Corcoran, R., Howard, R., Blackwood, N.& Kinderman, P. (2001) Persecutory
delusions: a review and theoretical integration. Clinical Psychological Review, 21,1143-
1192.
Blairy, S., Linotte, S., Souery, D., Papadimitriou, G.N., Dikeos, D., Lerer, B., et al. (2004) Social
adjustment and self-esteem of bipolar patients: a multicentric study. Journal of Affective
Disorder 79,97-103.
Bowins, B.& Shugar, G. (1998) Delusions and self-esteem. Canadian Journal of Psychiatry
43,154-158.
Brekke, J.S., Kohrt, B. & Green, M.F. (2001). Neuropsychological functioning as a moderator of
the relationship between psychosocial functioning and the subjective experience of self and
life in schizophrenia. Schizophrenia Bulletin 27, (4): 697-708.
Crocker, J.& Wolfe, C.T.( 2001) Contingencies of self-worth. Psychological Review, 108,593-623.
David, A., Buchanan, A., Reed, A., et al (1992) The assessment of insight in psychosis. British
Journal of Psychiatry, 161, 599 -60
Erickson MA, Lysaker PH. (2012) Self-esteem and insight as predictors of symptom change in
schizophrenia: a longitudinal study. Clinical Schizophrenia and Related Psychoses. 6(2):69-
75.
Garety, P.A., Kuipers, E., Fowler, D., Freeman, D.& Bebbington, P.E.(2001) A cognitive model of
the positive symptoms of psychosis. Psychological Medicine, 31,189-195.
Greenberg,J., Solomon, S., Pyszczynski, T.& Rosenblatt, A., Burling, J., Lyon. D, et al. (1992) Why
do people need self-esteem? Converging evidence that self-esteem serves an anxiety-
buffering function. Journal of Personality and Social Psychology 63,913-922.
Gureje, O., Harvey, C. & Herrman, H. (2004). Self-Esteem in patients who have recovered from
psychosis: profile and relationship to quality of life. Australian and New Zealand Journal of
Psychiatry 38, 334-338.
Holding JC1, Tarrier N, Gregg L, Barrowclough C. (2013) Self-esteem and relapse in
schizophrenia: a 5-year follow-up study. Journal of Nervous and Mental
Diseases.201(8):653-8.
Karatzias, T., Gumley, A., Power, K.& O'Grady, M. (2007)Illness appraisals and self-esteem as
correlates of anxiety and affective comorbid disorders in schizophrenia. Comprehensive
Psychiatry 4,371-375.
Kay SR, Fiszbein A, Opler LA.(1987) The positive and negative syndrome scale (PANSS) for
schizophrenia.Schizophrenia Bulletin. 13(2):261-76.
Link, B.G., Struening, E.L., Neese-Todd, S., Asmussen, S.& Phelan, J.C.( 2001) Stigma as a
barrier to recovery: The consequences of stigma for the self-esteem of people with mental
illnesses. Psychiatric Services 52,1621-1626.
McFarland, C., Ross, M.(1982) Impact of causal attributions on affective reactions to success and
failure. Journal of Personality and Social Psychology 43,937-946.
Robson, P.J. (1998). Self-Esteem- A Psychiatric View. British Journal of Psychiatry 153,6-15.
Sinclair SJ; Blais MA; Gansler DA; Sandberg E; Bistis K; LoCicero A. (2010) Psychometric
properties of the Rosenberg Self-Esteem Scale: overall and across demographic groups
living within the United States. Eval Health Prof;33(1):56-80
Silverstone, P.H.& Salsali, M. (2003) Low self-esteem and psychiatric patients: Part I - The
relationship between low self-esteem and psychiatric diagnosis. Annals of General Hospital
Psychiatry 2,2.
Sing-Fai,Tam., Yee-Chiu, I.P. & Cap Siu-Ching, Chan. (2000). Self-concepts of hospitalized and
day-care psychiatric patients. The Journal of Social psychology: 140, 2,202.
Smith, B., Fowler, D.G., Freeman, D., Bebbington, P., Bashforth, H., Garety., P, et al. (2006)
Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs
and delusions and hallucinations. Schizophrenia Research 86,181-188
 Sorgaard, K.W., Heikkila, J.& Hansson, L.,. (2002). Self-esteem in persons with schizophrenia. A
Nordic multicenter study. Journal of Mental Health 11, 405-415
Taylor, S. E., Peplau, L. A., & Sears, D. O. (2000). Social psychology .10th Ed. Upper Saddle
River, NJ: Prentice-Hall
Van Dongen, C.J. (1996) Quality of life and self-esteem in working and nonworking persons with
mental illness. Community Mental Health Journal 32,535-548.
== == = = = = = = == == = = = = = = == == = = = = = = == == = = = = = === == = = =

Prof. S.Kumar, M.D. Director and Dr. S.Mohanty, Ph.D. Research Officer; Institute of Mental
Health and Hospital, Agra – 282002 Email: imhh.agra@gmail.com

View publication stats