Low self-esteem and psychiatric patients - BioMed Central

Annals of General Hospital Psychiatry 2003, 2http://www.general-hospital-psychiatry.com/content/2/1/2simply representative of poor psychological health regardlessof the diagnosis.One of the major problems in the area of self-esteem researchis the lack of a clear consensus definition. Self-esteemhas been given a number of different definitions,each emphasising different aspects [4]. Hence, measurementinstruments based on different definitions sometimeshave poor correlation. An appropriate approach tobetter evaluate self-esteem may therefore be to use morethan one measure of self-esteem.Lowered self-esteem has been consistently found to occurin several psychiatric disorders. These include major depressivedisorder, eating disorders, anxiety disorders, andalcohol and drug abuse. For example, there are multiplestudies demonstrating that patients with major depressivedisorder have lowered self-esteem [2,8,9]. Lowered selfesteemhas also been considered a psychological hallmarkof most patients with eating disorders [10–12]. Indeed,lowered self-esteem has been suggested to be the finalcommon pathway leading to eating disorders [13,14].Studies have shown that with increasing anxiety self-esteemdecreases [15,16,5]. However, in a study comparingthe self-esteem of patients with different psychiatric diagnoses,patients with anxiety disorders had the highest selfesteem[17]. The relationship between alcohol dependenceand lowered self-esteem has also long been recognised[1,18,19]. A relationship between the use of drugsand low self-esteem has been demonstrated in a numberof studies [20–23].Despite these studies, it remains unclear whether loweredself-esteem occurs in a few discrete psychiatric conditions,or in all psychiatric conditions, and also whether self-esteemis equally lowered in different psychiatric conditions.The aim of the present study is to address theseissues.MethodsPopulation SampleThe current study was carried out on data collected on aconsecutive sample of 1,190 cases attending the Walk-Inclinic at the University of Alberta Hospital, Edmonton,Canada. The sample consisted of 957 psychiatric patients,182 cases with conditions not attributable to a mental disorderbut due to psychosocial stressors ("V-codes" inDSM-III R), and 51 controls who accompanied patientsand were themselves assessed but did not receive a psychiatricdiagnosis (controls). The Walk-In clinic refers to apsychiatric open access clinic where patients can referthemselves or be referred through a family doctor. A therapist,who is a psychologist, a social worker or a psychiatricnurse, sees each patient. Any diagnoses made are thenconfirmed during a subsequent interview with a psychiatrist,with a final consensus diagnosis being made accordingto DSM III-R criteria. It is common practice in theWalk-In clinic that frequently the individuals who accompanythe patient, particularly the family members, willalso be assessed. As part of the assessment, all subjectscomplete a questionnaire containing two self-esteemscales.Self-Esteem ScalesTwo well-recognized patient-completed questionnaireswere used to measure self-esteem. These were the Janisand Field Social Adequacy Scale (JF Scale) [24] and theRosenberg Self-Esteem Scale (Rosenberg Scale) [25]. TheJF Scale is available in Appendix 1 (see additional file 1)and the Rosenberg Self-Esteem Scale is available in Appendix2 (see additional file 2). The JF Scale consists of 23self-rating items, which measure anxiety in social situations,self-consciousness, and feelings of personal worthlessness.The maximum score is 115, and a higher scorereflects increased self-esteem. Reliability estimates basedon the Spearman-Brown formula and split-half reliabilityestimates for this scale are 0.91 and 0.83, respectively.The Rosenberg Scale measures global self-esteem and personalworthlessness. It includes 10 general statements assessingthe degree to which respondents are satisfied withtheir lives and feel good about themselves. In contrast tothe JF Scale, a lower score reflects higher self-esteem. Inthe original report, Rosenberg quoted a reproducibility of0.9 and a scalability of 0.7. The Rosenberg Scale has previouslybeen validated in other studies [25–27]. It is themost widely used scale to measure global self-esteem inresearch studies.Grouping of patientsIndividuals were categorized as being in one of the 19groups, including two groups of controls (the "psychosocialstressor" group and the healthy "control" group).Eleven of these groups, namely psychotic disorders; majordepression; dysthymia; bipolar disorder; anxiety disorders;alcohol use disorders; drug use disorders; eating disorders;adjustment disorder; conduct disorder; andimpulse control disorder were according to the DSM-III-Rclassification with two modifications: the group named"psychotic disorders" consisted of schizophrenia, andpsychotic disorders not elsewhere classified; the psychoactivesubstance use disorders was divided into two groups,namely "alcohol use disorders" (consisting of alcoholabuse and alcohol dependence) and "drug use disorders"(consisting of drug abuse and drug dependence). Fivegroups consisted of patients who had comorbid diagnoses.These groups were major depression and anxietydisorders; major depression and dysthymia; major depressionand alcohol use disorders; major depression anddrug use disorders; and alcohol and drug use disorders.Page 2 of 9(page number not for citation purposes)