Self-esteem, a global and complex concept, is comprised of both appraisal of self-worth based on personal achievements and anticipation of evaluation by others [1
]. Although not uniformly low, self-esteem is often found to be compromised among persons with mental illnesses [3
]. Low self-esteem is therefore of considerable interest as it is both a possible consequence and a possible cause of psychiatric symptoms [4
Regarding self-esteem as a consequence of mental illness, studies predictably show that stigmatization and self-stigmatization may lower self-esteem in persons with mental illness [7
]. Low self-esteem also appears to increase the risk of psychiatric disorders such as depression, eating disorders and substance abuse [8
]. In psychotic disorders, low self-esteem has been implicated in both the development of delusions [9
] and the maintenance of psychotic symptoms [11
Recent models of global self-esteem suggest that it is both a trait and a state measure [12
]. People have a typical, average or trait level of self-esteem, while their momentary, or 'state', judgments of self-esteem can fluctuate around this level dependent on social feed-back and self-judgment. Furthermore, it is the person's interpretation of the event or circumstance, and its relevance to his or her contingencies of self-worth, that determines both if
and how strongly
it will affect state self-esteem [12
]. It appears that treatment failures, functional loss, demoralization and stigmatization may lower self-esteem in patients with severe mental illnesses. To what extent low levels of self-esteem in severe mental disorders are based on underlying, or trait levels of self-esteem, and how this in turn may increase vulnerability to more severe symptoms has not been thoroughly explored. This is of importance both for the understanding of the mechanisms behind the development of psychotic symptoms and also for improving treatment as self-esteem can be influenced by therapeutic interventions [14
Studies have suggested that difficult childhood experiences such as childhood loss and social marginalization contribute to a cognitive vulnerability accompanied by a negative view both towards the person himself and towards others [4
]. It can be hypothesized that individuals with a history of poor premorbid adjustment, both social and academic, are more prone to negative self-evaluation and reduced global self-esteem. MacBeth and Gumley have shown in their review of premorbid adjustment and early symptom development that premorbid problems in psychosocial functioning are associated with a greater severity of illness course and, in particular, more negative symptoms [17
]. They also found that reduced quality of life (QoL) was reported by individuals with poorer premorbid functioning. Interestingly, the course of premorbid social adjustment has been found to exert a greater effect on QoL than premorbid academic adjustment [18
], and may also be more influential on trait self-esteem. This underlines the importance of separating the social and academic domains of premorbid adjustment.
To our knowledge only one study has tried to examine the relationship between premorbid adjustment and self-esteem in patients with schizophrenia spectrum disorder [19
]. They found no relationships between self-esteem and premorbid adjustment in recovered psychotic patients. However, premorbid adjustment was not assessed with a specific instrument which may account for the negative results.
A relatively rich literature exists on the relationship between low self-esteem and symptom formation in severe mental disorders including psychotic disorders. 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 persistence of delusions [20
]. Other studies found significant correlations between negative self-evaluation and a wider variety of positive symptoms i.e hallucinations and delusions, in schizophrenia [10
]. It has also 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 [21
]. In addition, it has been found that patients who had both high levels of suspiciousness and low self-esteem made more misattributions of anger which may also fuel delusional ideation [22
]. This is in line with findings from the general population, where delusion prone individuals show lower self-esteem [23
]. Finally, it has been found that several delusional themes including persecution, thought disturbances/thought broadcasting, catastrophic ideation, and negative self beliefs were related to low self-esteem [24
Other studies have shown higher levels of self-esteem in patients with delusional disorder compared to depressed patients [25
]. However, the authors found that the group without depressive symptoms had significantly higher levels of grandiose ideation than the other groups which may have accounted for the elevated levels of self-esteem. The authors concluded that persecutory delusions may reflect an attributional style protecting the individual from low self-esteem. The same has been hypothesized for grandiose delusions, but the few studies in this area do not clearly support this hypothesis [26
]. Other studies have found equal levels of self-esteem in patients with delusions and matched healthy controls with both groups demonstrating higher levels than depressed patients [27
Self-esteem has been found to fluctuate over the short-term. It has been demonstrated that paranoid individuals display more fluctuations in their self-esteem, and that the fluctuation predicts the degree of subsequent increase in paranoid thinking [28
]. However, other studies indicate that changes in both positive and negative beliefs about the self are related more to changes in negative symptoms than changes in paranoid symptoms [29
]. In summary the relationship between premorbid function, self-esteem and the formation of psychotic symptoms remains unclear.
To date the relationship between self-esteem, psychotic symptoms and premorbid adjustment in the early stages of psychosis has not been thoroughly explored. Previous studies of that nature have all been conducted with patients with chronic psychotic disorders where the effects of a long-term severe illness and secondary processes may significantly confound relationships. More studies are thus needed to explore the relationship between self-esteem and psychotic symptoms during the early phases of psychotic disorder. This is of importance as patients coming to their first treatment for a psychotic disorder are less influenced by stigmatization, treatment failures, and subsequent disappointments which may contribute to lowered self-esteem.
The aims of the current study are thus to investigate the following questions in a large and well characterized group of patients with first episode psychosis:
1) To what extent is premorbid adjustment (as measured by the Premorbid Adjustment Scale (PAS)), related to self-esteem (as measured by the Rosenberg Self- Esteem Scale (RSES)), in this patient group?
2) To what extent is self -esteem related to the level of hallucinations and delusions (as measured by the Positive and Negative Syndrome Scale (PANSS))?