The Role of Self-Esteem, Parenting Style, and

Outcome in First-Episode Psychosis:
The Role of Self-Esteem, Parenting Style, and Childhood Trauma
By
Nadia Vracotas
Supervisor: Dr. Ashok K. Malla
McGill University, Montréal
June, 2009
A thesis submitted to McGill University in partial fulfilment of the requirements
of the degree of
Master of Science (MSc)
In
Psychiatry
© Nadia Vracotas, 2009.
ACKNOWLEDGEMENTS
Foremost, I would like to thank my supervisor, Prof. Ashok Malla, for his
continued guidance and support. He shared with me a lot of his expertise and
research insight and quickly became for me the role model of a successful
researcher in the field. I would also like to express my gratitude to Drs. Ridha
Joober and Srividya Iyer, whose thoughtful advice often served to give me a sense
of direction during my studies.
Additionally, I would like to thank my colleagues at the Prevention and Early
Intervention Program for Psychosis (PEPP-Montréal) who have made the long
working days seem shorter, and my very close friends and family who have
always encouraged me to push harder. A very special thanks to CA, AV, and EA
As they have added to who I am and who I will become.
I am deeply grateful to the Canadian Institute of Health Research (CIHR) for their
continued support of research in psychosis.
Last, but certainly not least, I would like to thank all the clients who agreed to
participate in my research, as this thesis would not be possible without them.
2
CONTRIBUTIONS OF AUTHORS
As the first author of both manuscripts (chapters 3 and 4), I (Nadia Vracotas)
made a significant contribution regarding the formulation of hypothesis, research
design, data collection and analysis. As well, I was responsible for writing both
manuscripts.
Dr. Srividya Iyer has provided considerable input regarding the data analysis and
the interpretation of findings for the first manuscript (chapter 3).
Dr. Ridha Joober has provided substantial contributions with regards to
interpretation of findings for the first manuscript (chapter 3).
Dr. Ashok Malla has provided substantial contributions with regards to the
structure of the contents, research design and interpretation of findings for both
manuscripts (chapter 3 and 4).
3
ABSTRACT
Self-esteem is an important construct in psychiatric disorders. We hypothesize
that in patients with first onset of a psychotic disorder, self-esteem will be
associated with outcome and it will, in turn, be influenced by early life
experiences.
Methods: The Self-Esteem Rating Scale, The Parental Bonding Instrument (PBI),
the Measure of Parental Style (MOPS) and The Childhood Trauma Questionnaire
(CTQ) were administered to individuals with first-episode psychosis. Symptoms
and the GAF were assessed at entry to the program and at six months.
Results: Self-esteem was positively correlated with the GAF, but not with
remission status at six months. Self-esteem was negatively correlated with the
PBI Overprotection, MOPS Overcontrol and Abuse subscales, in relation to
mothers and also negatively with Emotional Neglect, Emotional Abuse and
Sexual Abuse subscales of the CTQ.
Conclusion: Self-esteem influences outcome in early psychosis and is in turn,
influenced by early life experiences. This may have implications for designing
special interventions to improve outcome.
4
RÉSUMÉ
L’estime de soi est un élément important dans le développement de troubles
psychiatriques. Nous posons l’hypothèse que chez les patients présentant des
signes avant-coureurs de trouble psychotique, l’estime de soi sera associée avec le
pronostic et elle sera en retour influencée par les expériences en début de vie.
Méthode: L’échelle de mesure de l’estime de soi (The Self-Esteem Rating Scale),
la mesure sur l’attachement parental (PBI), l’instrument de mesure sur le style
d’attachement (MOPS) et le questionnaire des traumatismes de l’enfance (CTQ)
ont été administrés aux individus confrontés à un premier épisode psychotique.
Les symptômes et le niveau de fonctionnement global (GAF) ont été évalués à
l’entrée du programme et six mois plus tard.
Résultats: L’estime de soi était corrélée positivement avec le GAF, mais elle
n’était pas corrélée avec le statut de rémission à six mois. L’estime de soi était
négativement corrélée avec la surprotection du PBI, les échelles de surcontrôle et
d’abus du MOPS, en relation avec les mères. L’estime de soi était aussi
négativement corrélée avec les échelles de négligence émotionnelle, d’abus
émotionnel et sexuel du CTQ.
Conclusion: L’estime de soi influence le pronostic de psychoses précoces et, en
retour, elle est influencée par les premières expériences de vie. Ceci pourrait avoir
5
des implications afin de développer des interventions spécialisées améliorant le
pronostic.
6
TABLE OF CONTENTS
Acknowledgements..........................................................................................2
Contributions of Authors................................................................................3
Abstract……………………………………………………………..………..4
Résumé…………………………………………………………………...…...5
CHAPTER 1-Background and Objectives
1.1.
Introduction…………………………………………….……………..10
1.2.
Outcome Studies in Psychosis…………………………….………….11
1.3.
Studies on Self-Esteem……………………………………………….12
1.4.
Self-Esteem and Early Life Experiences……………………………..14
1.5.
Self-Esteem and Functional Outcome…………………………….….16
1.6.
The objective of the study……………………………………………16
1.7.
Hypotheses…………………………………………………………...18
CHAPTER 2-Method
2.1.
Setting……………………………………………………………..…19
2.2.
Subjects………………………………………………………………19
2.3.
Measures……………………………………………………………..20
2.3.1. Diagnosis…………………………………………………………….20
2.3.2. Patient characteristics………………………………………………..20
2.3.3.1. Dependent variables………………………………………….……..21
2.3.3.1.1. Outcome…………………………………………………..………21
a. Global Assessment of Functioning……………………………......21
b. Remission…………………………………………………….…22
7
2.3.3.2. Independent Variables…………………………………………….22
2.3.3.2. Symptoms…………………………………………….…………...22
2.3.3.2.2. Pre-Morbid Adjustment Scale……………………………….….22
2.3.3.2.3. The Self-Esteem Rating Scale…………………………………..23
2.3.3.2.4. Perception of Childhood experience…………………….………23
a. Parental bonding Scale………………………………….…….....23
b. Measure of Parental Style…………………………………….....23
2.3.3.2.5. The Childhood Trauma Questionnaire………………….………25
2.4. Data Analysis…………………………………………………………27
CHAPTER 3-Manuscript 1:
“The Role of Self-Esteem for Outcome in First-Episode Psychosis”
3.1.
Abstract…………………………………………………………….31
3.2.
Clinical implications & Limitations……………………………….33
3.3.
Introduction………………………………………………………..34
3.4.
Method…………………………………………………………….36
3.5.
Results……………………………………………………………..41
3.6.
Discussion ……………………………………………………..….43
3.7.
Conclusion………………………………………………………...46
3.8.
References………………………………………………………....48
8
CHAPTER 4-Manuscript 2:
“The Role of Early Life Experiences in determining Self-Esteem in Patients with
First-Episode Psychosis”
4.1.
Abstract……………………………………………………….………….53
4.2.
Introduction…………………………………………………….………...55
4.3.
Method…………………………………………………………………...57
4.4.
Results……………………………………………………………………63
4.5.
Discussion………………………………………………………………..66
4.6.
Conclusion……………………………………………………………….68
4.7.
References………………………………………………………………..69
4.6.
Table 1……………………………………………………………………74
4.7.
Table 2……………………………………………………………………75
CHAPTER 5
5.1.
Discussion……………………………………………………………….76
5.2.
Conclusion………………………………………………………..……..81
REFERENCES…………………………………………….…………………..82
APPENDIX A:
a. Consent form....………………………………………………………………92
b. Assent form…………………………………………………………………..95
9
CHAPTER I
INTRODUCTION
Psychotic disorders have a life time risk prevalence of more than 2% for
non-affective psychosis alone (van Os, Hanssen, Bijl & Ravelle, 2000), with an
annual incidence of 30.4 per 100,000 of non-affective and affective psychosis
(Proctor, Mitford & Paxton, 2004). Psychosis is a brain disorder, which is
characterized by positive and negative symptoms. Positive symptoms include
hallucinations, delusions, disorganized behaviour, and positive formal thought
disorder. Negative symptoms include poverty of thought and affect, apathy,
emotional and social withdrawal, anhedonia, and avolition. Additionally,
individuals suffering from psychosis may also experience depressive, manic, and
anxiety symptoms.
The onset of psychosis is typically between the young ages of 16 and 27
years old. Considering the early part of life that is affected by these disorders, the
onset may interfere with social and emotional maturation, higher education,
employment, marriage and parenthood, and has been found to be associated with
higher rates of substance abuse (Regier et al., 1990; Green, Noordsy, Brunette, &
O’Keefe, 2008), depression (Koreen et al., 1993), suicide (Palmer, Pankratz, &
Bostwick, 2005; Westermeyer, Harrow & Marengo, 1991), violence and legal
problems. Psychotic disorders and particularly schizophrenia spectrum disorders
are the most expensive mental disorders in terms of direct costs, loss of
productivity, and expenditures for public assistance (Rice & Miller, 1996).
10
1.2. Outcome Studies in Psychosis
Despite advances in treatment there is considerable heterogeneity in both
clinical and functional outcome in psychotic disorders. Long-term outcome
studies have revealed three main trajectories of outcome following treatment of a
first-episode of psychosis (Huber, Gross, Schuttler, & Linz, 1980; Harrison et al.,
1996). It has been documented that 15 to 20 % of all cases result in a favorable
outcome, 20 to 25% of all cases do not respond to treatment and therefore decline
in functioning, and 50 to 60% of individuals experience an episodic course of
illness characterized by residual symptoms and social and personal deficits
(Harrow, Grossman, Jobe, & Herbener, 2005; Wiersma, Nienhuis, Slooff, & Giel,
1998; Lenior, Dingemans, Schene, & Linszen, 2005). It is also important to note
that outcome at one or two years after treatment of a first-episode of psychosis is
highly predictive of long-term outcome (Carpenter & Strauss, 1991; Harrison et
al., 2001). Short-term functional outcome has in turn shown to be associated with
female gender (Simonsen et al., 2007), level of negative symptoms at admission
(Ho, Nopoulos, Flaum, Arndt, & Andreasen, 1998) and at three months
(Simonsen et al., 2007), residual positive and negative symptoms at one year
(Malla, Norman, Manchanda, & Townsend, 2002a), pre-morbid adjustment
(Simonsen et al., 2007; Malla et al., 2002b; Addington, 2003; Ho, Andreasen,
Flaum, Nopoulos, & Miller, 2000), onset during childhood or adolescence and
duration of untreated psychosis (Simonsen et al., 2007; Harrigan, McGorry &
Krstev, 2003; Schmidt, Blanz, Dippe, Koppe, & Lay, 1995; Jarbin, Ott & Von
Knorring, 2003), and finally, deficits in verbal and working memory (Bodnar,
Malla, Joober, & LePage, 2008). Although, several predictors of outcome have
11
been identified, the role of individuals’ self-esteem in the early course of
psychotic disorders remains to be studied. As well, there seems to be a
considerable gap between symptom remission and functional outcome. Selfesteem may play a significant role in understanding this discrepancy.
1.3. Studies on Self-Esteem
Self-esteem as a potential factor contributing to outcome has not been
investigated enough, however, it has been suggested that low self-esteem may be
an important concept potentially related to the etiology, understanding and
treatment of a wide range of psychiatric conditions (Silverstone, 1991;
Markowitz, 2001; Bardone, Vohs, Abramson, Heaatherton, & Joiner, 2000;
Roberts & Monroe, 1994; Clarke & Kissane, 2002; DuBois & Flay, 2004; Emler,
2001), including psychotic disorders (Freeman et al., 1998; Bradshaw & Brekke,
1999; Roe, 2003). Silverstone (1991) observed lower levels of self-esteem among
psychiatric patients when compared to a control group, where individuals
diagnosed with personality disorders and depression exhibited the lowest selfesteem, and individuals diagnosed with anxiety disorders the highest self-esteem.
In fact self-esteem has also been investigated in psychotic disorders, and
has repeatedly been implicated in the formation (Kinderman & Bentall, 1996;
Colby, 1977) and maintenance of delusions (Bowins & Shugar, 1998) and
hallucinations (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). Brekke,
Levin, Wolko, Sobel, and Slade (1993) found a positive relationship between low
self-esteem and low psychosocial functioning in individuals suffering from
schizophrenia. Psychosocial functioning was defined by employment, living
12
status, social functioning (Community Adjustment Form; Test et al. 1991),
intrapsychic deficits (subscale of the Quality of Life Scale; Heinrichs, Hnlon, &
Carpenter, 1984), and symptomatology (The Brief Psychiatric Rating Scale;
Overall & Gorham, 1962). Preliminary research suggests that even in patients
who show significant improvement in positive and negative symptoms, persistent
low self-esteem may increase vulnerability for relapse (Gummley et al., 2006). In
one study, a sample of 132 individuals suffering with a severe mental disorder,
self-esteem at baseline, six, 12, and 18 months was highly correlated with life
satisfaction (Quality of Life Interview) and Affect (Brief Psychiatric Rating
Scale) ratings (Torrey, Mueser, McHugo, & Drake, 2000), but not with functional
status, housing and income. Torrey and colleagues concluded that self-esteem
appears to be a relatively stable trait that reflects general life satisfaction and
affective symptoms rather than objective functional status.
Researchers in depression believe low self-esteem may contribute to
vulnerability in the development of depression (Beck, 1967; Browns & Harris,
1978). Given that depression is common (prevalence 22% to 75%) among
individuals who suffer from schizophrenia (Koreen et al., 1993), the relationship
between symptoms and experiences of psychosis and level of self-esteem appears
to be an important area for investigation. For example, Vracotas, Schmitz, Joober,
and Malla (2007) found that distress experienced by individuals suffering from a
FEP was likely associated with level of self-esteem, depression, and anxiety, but
not positive or negative symptoms. Moreover, the relationship between distress
and levels of depression and anxiety was likely mediated by level of self-esteem.
These studies seem to support the hypothesis that level of self-esteem may be of
13
significance in the progression of severe mental illness. Little is known, however,
about the longer term potential relationship between psychosis and self-esteem.
1.4. Self-Esteem and Early Life Experiences
We are even more limited in our knowledge about what factors influence
the level of self-esteem early on in psychosis. It has been well established that the
quality of parenting received (Sato, et al. 1998; Thomasgard & Metz, 1996;
Thomasgard & Metz, 1999) and childhood trauma (Browne & Finkelhor, 1986;
Paz, Jones & Byrne, 2005; Read, van Os, Morrison, & Ross, 2005) have direct
and lifelong effects on psychological well-being in the general population. Thus,
early life experiences such as overprotection or control, indifference, abuse and
lack of care by a parent, as well as various traumas that may have occurred in
childhood or adolescence, such as physical neglect or abuse, emotional neglect or
abuse or sexual abuse, could contribute to the development of self-esteem later on
in life.
It has been well established that childhood traumas may have numerous
negative implications for mental health, physical health, and social outcomes later
on in life (Sato, et al. 1998; Thomasgard & Metz, 1996; Thomasgard & Metz,
1999; Browne & Finkelhor, 1986; Paz, Jones & Byrne, 2005; Read, et al., 2005).
Numerous studies have linked perceived parenting styles to adult depression
(Parker, 1983; Parker, Kiloh & Hayward, 1987; Parker, 1993). A longitudinal
study by Miller, Warner, Wickramaratne, and Weissman (1999) investigated
daughters of mothers who were experiencing depression. The study found that
maternal ‘affectionless control’ (i.e. high overprotection and low care) was
14
associated with low self-esteem and depression in their daughters at a 10 year
follow up.
Parker, Fairley, Greenwood, Jurd, and Silove (1982) investigated the
association of parental care and protection on the onset and course of illness in a
sample of individuals who had recently been discharged from the hospital for a
psychotic episode. They found that scores on the Parental Bonding Instrument
(PBI) suggested that these individuals were exposed to lower parental care and
higher paternal protection than matched controls (non-clinical). Participants were
more likely to assign their parents to the ‘affectionless control’ quadrant than the
‘optimal bonding’ quadrant (i.e. high care and low overprotection). However, this
finding was only significant in relation to fathers. In a later study by the same
group of researchers (Parker & Mater, 1986) these findings were replicated.
Interestingly, in the earlier study, those who assigned at least one parent to the
affectionless control quadrant and still had contact with them were 75% more
likely to be readmitted within the following nine months.
Self-esteem may also be associated with early life abuse or neglect which
may not necessarily be related to parental variables. Previous studies have
reported that children who have been maltreated exhibit higher scores on
neuroticism (Rogosch & Cicchetti, 2004), show less social competence (Kinard,
1999), have higher risk of borderline personality disorder (Machizawa-Summers,
2007; see review Graybar & Boutilier, 2002), and antisocial personality disorders
(Jaffee et al., 2004).
Bolger, Patterson, and Kupersmidt (1998) found that difficulties in peer
relationships and lower self-esteem were associated with greater severity and
15
chronicity of maltreatment. Specifically, children who experienced chronic
maltreatment were less well-liked by peers. Additionally, the type of maltreatment
was associated differentially to specific aspects of children's adjustment. For
example, sexual abuse predicted low self-esteem, but not problems in peer
relationships. Emotional maltreatment, on the other hand, was related to
difficulties in peer relationships, but not to low self-esteem. Interestingly the
authors found that for some groups of maltreated children, having a good friend
was associated with improvement in self-esteem over time.
1.5. Self-Esteem and Functional Outcome
Low self-esteem in concert with other factors may contribute to
vulnerability and to a greater persistence of symptoms and/or lack of functionality
in individuals diagnosed with schizophrenia (Ritsner & Susser, 2004;
Barrowclough et al., 2003). In order to increase our understanding of the role
played by potential influences on outcome, we need to apply a more
comprehensive integrative model, addressing research questions in a well
characterized sample of individuals suffering from a first-episode psychosis (FEP)
who have not received long periods of pharmacological treatment and periods of
hospitalizations.
1.6. The objective of the study
The objective of the current study is to examine the impact of self-esteem in
individuals who presented for treatment of a first-episode of psychosis on
16
outcome early in the course of the illness, as well as, investigate the influence that
early life experiences have on the development of self-esteem in these individuals.
17
1.7. Hypotheses
Primary:
The level of a patient’s self-esteem early in the course of treatment of FEP will
influence response to treatment, evaluated by the Global Assessment of
Functioning (GAF) measure at six months following initiation of treatment. In
other words, those who exhibit higher levels of self-esteem will show better rates
of functional outcome and symptom remission at six months. Self-esteem was
operationally defined as the confidence in one’s own worth or abilities.
Secondary:
1) The level of self-esteem is likely related to patient’s perception of childhood
experiences of the quality of parental care including overprotection, over
controlling and abuse. Specifically, individuals who have experienced parents as
highly overprotective and/or over controlling and/or abusive and/or less caring
will present with lower self-esteem and may possibly show poorer rates of
improvement.
2) The level of self-esteem is likely related to the level of trauma the patient may
have experienced as a child or adolescent. Specifically, individuals who have
experienced more abuse (emotional, physical, and sexual) and/or neglect
(emotional and physical) growing up may exhibit lower levels of self-esteem and
possibly show poorer rates of improvement.
18
CHAPTER 2
METHOD
2.1. Setting
Subjects were recruited from the Prevention and Early Intervention
Program for Psychosis (PEPP) in Montréal, Québec, Canada. PEPP is a
specialized service providing assessment, treatment and follow-up to patients
suffering from a FEP in one sector of Montréal. There are no other competing
services in this sector. Referrals to PEPP were received from various services and
organizations in the community including hospital emergency services,
community physicians and mental health services, educational counselors,
parents, police, etc. The sample recruited is highly representative of a community
sample of first onset and largely untreated cases.
2.2. Subjects
Criteria for admission to PEPP-Montréal and for the studies described in
this thesis include; age between 14 and 30 years old, Diagnostic and Statistical
Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR; American
Psychiatric Association, 2000) diagnosis of a psychotic disorder and not having
received antipsychotic medication for greater than one month. Patients with an IQ
of < 70, or a diagnosis of organic brain syndrome or epilepsy are excluded.
Primary diagnosis of substance abuse/dependence is an exclusion criterion but
concurrent substance abuse with a primary diagnosis of psychotic disorder is not.
All patients provided an informed consent within the first month of entry to the
19
program for conducting all evaluations as part of a longitudinal study of outcome.
For participants under the age of 18 years old, parental consent was obtained as
well. All consent forms and assessment protocols have been approved by the
institutional human ethics board (see Appendix A). Clients were approached to
complete assessments and consent only when they were stable enough to fully
understand what was being asked of them.
2.3. Measures
All clinical diagnostic assessments and symptom ratings were carried out
by trained research staff and supervised by at least 2 senior psychiatrists.
2.3.1. Diagnosis
DSM-IV-TR diagnosis was established with the Structured Clinical
Interview for DSM-IV-TR Axis I Disorders-Patient Edition (First et al., 2002)
within the first 3 months of entry to the program and confirmed through
consensus between two senior psychiatrists and the interviewer.
2.3.2. Patient characteristics
The Topography of Psychotic Episode (TOPE) and the Circumstances of
Onset and Relapse Schedule (CORS), which include some material adapted from
the Interview for Retrospective Assessment of Onset of Schizophrenia (Häfner et
al. 1992), were administered during the first three months of treatment by research
staff trained to conduct these interviews. The information obtained includes basic
demographic characteristics, the time of onset of any psychiatric symptoms and
20
the onset of psychotic symptoms. Psychiatric symptoms occurring prior to onset
of psychosis refer to symptoms such as anxiety, depression, suicidal ideation and
social withdrawal (Norman et al., 2005). Duration of untreated psychosis (DUP)
was calculated as the period beginning with the time of onset of psychotic
symptoms to the date of initiation of adequate antipsychotic treatment (Malla et
al., 2002; Malla et al., 2006). Duration of untreated illness (DUI) was defined as
the period beginning with the first onset of any psychiatric symptoms to the time
of adequate antipsychotic medication. Adequate treatment was defined as taking
anti-psychotic medication for a period of one month or until significant response
whichever came first. Final ratings on DUP and DUI were arrived at through
consensus between the interviewer and at least two senior research-clinicians
based on a review of the information available.
2.3.3.1. Dependent variables
2.3.3.1.1 Outcome
a. Global functioning was assessed using The Global Assessment of Functioning
(GAF; Spitzer et al., 1966) scale. The GAF was completed at baseline and six
months. The GAF, an ordinal scale (Range: 1 to 100) with 10 categories of 10
points each, is used to rate the social, occupational and psychological functioning
of patients and is widely used in psychiatric research. Ratings are arrived at by
selecting first a category then checking the category above and below to ensure
the correct category based on patient’s level of functioning and symptoms
following which an actual score is given within the chosen category.
21
b. Remission of psychosis was defined as either total absence of psychotic
symptoms or at a level below that of threshold for psychosis. Patients were
considered to have achieved remission of positive symptoms if they showed either
no evidence or a mild level of psychotic symptoms (delusions, hallucinations,
thought disorder and bizarre behavior) lasting for at least 1 month, equivalent to a
global rating of 2 or less on each of the global subscales on the Scale for
Assessment of Positive Symptoms (SAPS; Andreasen, 1984).
2.3.3.2. Independent Variables
2.3.3.2.1. Symptoms Psychotic and negative symptoms were assessed at baseline
and at six months with the SAPS and the Scale for Assessment of Negative
Symptoms (SANS; Andreasen, 1983), respectively, whereas depression and
anxiety were assessed with the Calgary Depression Scale (CDS; Addington et al.,
1992) and the Hamilton Anxiety Scale (HAS; Riskind et al., 1987), respectively.
2.3.3.2.2. Pre-morbid functioning The Pre-morbid Adjustment Scale (PAS;
Cannon-Spoor, Potkin, & Wyatt, 1982) was used to assess adjustment during
childhood (up to 11 years old), early adolescence (11-15 years old) and late
adolescence (16-19 years old) on social and educational dimensions. We chose to
include only the childhood and early adolescence periods to avoid any possible
overlap with onset of early psychotic or prodromal symptoms. The total score on
the PAS was calculated by adding the scores on all items and dividing by the total
possible score. The final score is thus the proportion bound between 0 (best
22
possible) and 1 (worst possible). The same procedure was used for each
dimension and each period.
2.3.3.2.3. Self-esteem The Self-Esteem Rating Scale (SERS; Nugent & Thomas,
1993) was administered within the first six months of treatment. The SERS is a
40-item self-rating scale with scores, with a range from -120 to 120, with higher
scores denoting higher and more positive self-esteem. The SERS has
demonstrated high reliability (coefficient alpha = 0.97) and good validity and has
been validated in individuals suffering from schizophrenia. It is suitable for use
with English (Nugent & Thomas, 1993) and French speaking populations
(Lacomte, Corbiere & Laisne, 2006). The SERS includes statements that tap into
multiple aspects such as self-worth, social competence, problem-solving ability,
intellectual ability, self-competence, and basic worth compared to others.
2.3.3.2.4. Perception of childhood experience will be measured using The
Parental Bonding Instrument (PBI; Parker, Tupling & Brown, 1979) and the
Measure of Parental Style instrument (MOPS; Parker et al., 1997). The PBI and
the MOPS are measures of perceived quality of parenting received during the
respondents’ first 16 years of life. Both scales are rated on a likert scale from 0 to
3. Items on the PBI are arranged so that some questions are asked in the negative,
and therefore have to be transformed, giving a rage of 0-39 for the protection
scale and 0-36 for the care scale, with higher scores indicating greater care and
protection. The scale can be used to assign parents to one of four style quadrants;
optimal parenting (high care - low overprotection), affectionless control (low care
23
- high overprotection), affectionate constraint (high care - high overprotection),
and neglectful parenting (low care - low overprotection). Suggested cut-off care
and protection scores are 27.0 and 13.5 for mothers and 24.0 and 12.5 for fathers
(Parker, 1983).
The psychometric characteristics have been examined across several
samples by different investigators over the years. The samples are made of a
range in gender, ages, income brackets, race and ethnicities, and diagnoses. The
factorial structure of the PBI has been confirmed in non-clinical and clinical
groups, and supported by independent demonstration of a similar two-factor (Care
and overprotection) model of parenting (Arrindell et al., 1986).
Reliability was assessed in an American study of 153 medical students (Richman
& Flaherty, 1986). Cronbach’s alpha scores ranged from 0.87 (paternal
overprotection) to 0.93 (paternal care). In another study (Fendrich, Warner, &
Weissman, 1990) examining family disharmony and parental depression as risk
factors for psychopathology in the offspring, the questionnaire was completed by
153 individuals (offspring of 65 families) with at least one depressed parent and
67 individuals (offspring of 26 families) with non-depressed parents. The
following Chronbach’s alphas were generated: 0.77 (maternal Care); 0.83
(maternal Overprotection); 0.83 (paternal Care); 0.86 (paternal Overprotection).
Test-retest Reliability is high over months, and moderate consistency has
been reported over periods up to ten years. In an epidemiological community
study conducted in Australia by Mackinnon and colleagues (1989), three hundred
and eighty six individuals completed the initial questionnaire. The group was
divided into four subgroups. The four subgroups were retested at different time
24
points (4, 11, 21, and 34 week). Ninety-six percent (n = 369) of the participant
complied. Test-retest coefficients ranged from 0.89 to 0.94 for paternal Care and
0.74 to 0.89 for paternal Overprotection.
2.3.3.2.5. Childhood Trauma was assessed using The Childhood Trauma
Questionnaire (CTQ; Bernstein & Fink, 1994; Bernstein & Fink, 1998). The CTQ
is a 28-item self-report retrospective inventory designed to measure childhood or
adolescent abuse and neglect (maltreatment). The CTQ is appropriate for use in
adolescents (age 12 years old and over) as well as adults. In the current study,
individuals were asked to take into consideration the first 16 years of their life to
remain consistent with the PBI and MOPS. The CTQ contains five subscales,
three assessing abuse (Emotional, Physical, and Sexual), and two assessing
neglect (Emotional and Physical). Five items are assigned to each subscale and
the three items which remain produce a Minimization-Denial subscale to account
for extreme response bias by detecting false-negative trauma reports. The items
are endorsed on a 5-point Likert scale from 1 to 5, which corresponds to never
true to very often true, respectively. Therefore each subscale score ranges from no
history of abuse or neglect (total score of 5) to very extreme history of abuse or
neglect (total score of 25).
The CTQ items reflect common definition of child abuse and neglect as per most
common childhood trauma literature (i.e. Finkelhor, 1994; Knutson, 1995;
Malinosky-Rummell& Hansen, 1993).
25
Emotional Abuse refers to verbal assaults on a child’s sense of worth or wellbeing, or any humiliating, demeaning, or threatening behaviour directed
toward a child by an older person.
Physical Abuse refers to bodily assaults on a child by an older person that
pose a risk of or results in injury.
Sexual Abuse refers to sexual contact or conduct between a child and older
person; explicit coercion is a frequent but not essential feature of these
experiences.
Emotional Neglect refers to the failure of caretakers to provide a child’s basic
psychological and emotional needs, such as love, encouragement, belonging,
and support.
Physical Neglect refers to the failure of caregivers to provide a child’s basic
physical needs, including food, shelter, safety and supervision, and health.
(Page 2, CTQ-Manual, Bernstein & Fink, 1998)
The psychometric characteristics were examined across seven samples of
individuals (N = 2,201). The seven samples were made up of three psychiatric
populations (Adult substance abusers, adolescent psychiatric inpatients, and adult
psychiatric outpatients), 2 female chronic pain populations (Fibromyalgia and
rheumatoid arthritis) and 2 non-clinical populations (College undergraduates and
randomly selected female members of a health maintenance organization).
Therefore, the samples represent men and women from a broad range of ages,
income brackets, race and ethnicities, and diagnoses.
26
Internal consistency coefficients (Cronbach’s alpha) range from satisfactory to
excellent, with the highest for the Sexual Abuse subscale (median = 0.92) and the
lowest for the Physical Neglect subscale (median = 0.66). Refer to table 1 for all
of the validation samples.
Test-retest reliability was assessed with the sample of adult substance abusers.
Forty methadone-maintained outpatients were re-administered the CTQ after a
testing interval (range: 1.6 to 5.6 months; mean = 3.6; SD = 1.0). Interclass
correlation coefficients between the first and second testing were high (Emotional
Abuse, r = .80; Physical Abuse, r = .80; Sexual Abuse, r = .81; Emotional
Neglect, r = .81; Physical Neglect, r = .79; overall, r = .86).
Content Validity is demonstrated in terms of providing a broader, more
comprehensive content coverage. As previously mentioned CTQ items were
written to reflect domains described in the maltreatment literature (Crouch &
Milner, 1993; Finkelhor, 1994; Knutson, 1995; Malinosky-Rummell & Hanen,
1993), however, previous measures of childhood trauma have usually focused on
only one or two forms of maltreatment.
2.4. Data Analysis
The Statistical Package for Social Science (SPSS) for Window version
15.0 was used for statistical analysis. Means, standard deviations (SD) and
frequencies were computed to summarize the distribution of values for each
variable. Data were normally distributed except for the scores on the following
measures: DUP, GAF at baseline, CTQ, and MOPS mother and father
27
indifference and abuse subscales. Given the skewed distribution, non-standardized
statistical tests were implemented in the analyses.
To test for group differences on demographic and symptom variables
between individuals who participated and those who did not participate or who
had incomplete data, independent samples t-tests and Pearson Chi-squares were
computed as appropriate.
In the first study (n = 121) presented (Chapter 3), a Pearson bi-variate
correlation was conducted between scores on the SERS, GAF at six months,
followed by a linear regression in order to control for any possible covariates
which have been shown in previous studies to have an influence on outcome, such
as, GAF at baseline, premorbid adjustment, DUP, and gender. Finally, a logistic
regression was conducted, with remission status (a categorical variable) at six
month following initiation of treatment as the dependent variable, and self-esteem
as the predictor variable.
In the second study (n = 75) presented (chapter 4), Spearman’s bivariate
correlations were conducted between subscale scores from the PBI, MOPS, CTQ
and the SERS. Then, we conducted a stepwise regression analyses to evaluate the
independent contribution of each of the predictor variables (subscales of PBI,
MOPS, and CTQ), which had shown significant bivariate correlations. With Selfesteem as the dependent variable, we first entered the predictor variable shown to
elicit the strongest relationship with the dependent variable. Subsequent models
were added according to additional predictor variables, which had previously
elicited a correlation.
28
In order to control for any possible covariates that have been shown in
previous studies to have an influence on self-esteem, such as depression, anxiety,
and negative symptom, another regression analysis was conducted including any
subscale of the PBI, MOPS or CTQ that remained significant after the previous
regression analysis.
29
CHAPTER 3: Manuscript 1.
The Role of Self-Esteem for Outcome in First-Episode Psychosis
Nadia Vracotas, MSc Candidate1; Srividya N. Iyer, PhD2; Ridha Joober, MD,
PhD3; Ashok Malla, MBBS, FRCPC4
Prevention and Early Intervention Program for Psychosis (PEPP)
Douglas Mental Health University Institute
McGill University
6875 Boul. LaSalle, Montréal, Quebec, H4H 1R3, Canada
1
Student, McGill University, PEPP Montreal, Douglas Hospital Research Centre,
Montréal, Québec.
2
Post-Doctoral Fellow, McGill University, PEPP Montreal, Douglas Hospital Research
Centre, Montréal, Québec.
3
Associate Professor, Department of Psychiatry, McGill University, Douglas Hospital
Research Centre, Montréal, Québec.
4
Professor of Psychiatry, McGill University, Montréal, Québec; Director, Division of
Clinical Research, Douglas Mental Health University Institute, Montréal, Québec.
Corresponding author:
Ashok Malla
Professor, Department of Psychiatry,
Douglas Mental Health University Institute, McGill University,
6875 Boul. LaSalle, Montréal, Quebec, H4H 1R3, Canada
Office:1(514)761-6131 ext: 3418/3390
Fax:1(514)888-4064
[email protected]
30
ABSTRACT
Background: Self-esteem may be associated with a wide range of psychiatric
disorders, including psychotic disorders. However, a putative relationship
between self-esteem and outcome in psychosis has not been adequately examined,
especially early in the course of the illness.
Hypothesis: The level of a patient’s self-esteem assessed early in the course of
treatment of a first-episode psychosis will influence outcome as evaluated by the
Global Assessment of Functioning (GAF) and symptom remission at six months
following treatment.
Study design: The Self-Esteem Rating Scale (SERS) was administered to 121
individuals with first-episode psychosis following entry into a specialized
program. Symptoms and the GAF were assessed at and six months after
beginning treatment. A correlational analysis was followed by a linear regression
controlling for potential confounds.
Results: Self-esteem assessed early in the course of treatment was positively
correlated with GAF at six months (r = 0.281, p <.01). A linear regression
analysis conducted with GAF and depression at baseline in addition to gender,
pre-morbid adjustment, duration of untreated psychosis (DUP), and self-esteem as
predictors and GAF at six months as the outcome variable revealed only selfesteem to be a significant predictor of GAF at six months (β = 0.290, p < .01).
31
Self-esteem, however, did not influence remission at six months (β = 0.003, p >
.05).
Conclusion: Self-esteem is associated with global functional outcome at six
months but not with remission of symptoms. Efforts should be made to provide
interventions which may improve low self-esteem in the attempt to influence
functional outcome.
KEY WORDS: First-Episode Psychosis, Self-Esteem, Outcome
32
Clinical Implications
•
Self-esteem may be associated with global functional outcome in
individuals receiving treatment of a first-episode of psychosis.
•
Self-esteem may not be as important for the remission of psychotic
symptoms.
•
There may be some value in introducing an intervention to improve selfesteem for those receiving treatment for a first-episode of psychosis.
Limitations
•
Individuals in the sample were both affective and non-affective psychosis.
It is possible that those who presented with an affective psychosis had
different levels of self-esteem and/or outcome scores however, the
relatively small proportion of affective psychosis patients did not justify a
separate analysis.
•
Based on the correlational nature of this study, conclusions regarding the
causal role of self-esteem in determining outcome cannot be assumed.
•
This study is based on patients early on in treatment, and therefore, as
symptoms diminish further or stabilize these results may not hold true.
33
INTRODUCTION
Despite advances in treatment there is considerable heterogeneity in both clinical
and functional outcome in psychotic disorders. Many studies have shown shortterm functional outcome to be associated with female gender (Simonsen E, et al.,
2007), level of negative symptoms at admission (Ho et al., 1998) and at three
months (Simonsen E, et al., 2007), residual positive and negative symptoms at
one year (Malla et al., 2002a), pre-morbid adjustment (Simonsen E, et al., 2007;
Malla et al., 2002b; Addington, 2003; Ho et al., 2000), onset during childhood
and adolescence (Harrignan, McGorry & krstev, 2003; Schmidt et al., 1995;
Jarbin, Ott & Von Knorring, 2003), deficits in verbal and working memory
(Bodnar et al., 2008), and duration of untreated psychosis (Simonsen E, et al.,
2007; Harrignan, McGorry & krstev, 2003; Schmidt et al., 1995; Jarbin, Ott &
Von Knorring, 2003). Although, several predictors of outcome have been
identified, the role of individuals’ self-esteem in the early course of psychotic
disorders remains to be studied.
It has been suggested that low self-esteem may be an important concept
potentially related to the etiology, understanding and treatment of a wide range of
psychiatric conditions (Silverstone, 1991; Markowitz, 2001; Bardone et al., 2000;
Robert’s & Monroe, 1994), including psychotic disorders (Freeman et al., 1998;
Bradshaw & Brekke, 1999; Roe, 2003). In fact, self-esteem has repeatedly been
implicated in the formation (Bentall, kinderman, & kaney, 1994; Kinderman &
Bentall) and the maintenance of delusions (Bowins & Shugar, 1998) and
34
hallucinations (Garety et al., 2001). Bentall and colleagues have proposed that
paranoid delusions result from attempts to maintain self-esteem in individuals
with underlying low self-worth (Bentall, kinderman, & kaney, 1994; Kinderman
& Bentall; Bentall & Kaney, 1996). Others have proposed that in experiencing a
psychotic episode and possible hospitalization individuals are likely to suffer loss
of self-esteem making them vulnerable to developing post-psychotic depression
(Birchwood & Iqbal, 1998; Iqbal et al., 2000). Initial diagnosis of a psychotic
disorder and subsequent entry into treatment are likely to have some traumatic
effect on a young individual previously naïve to the mental health system (Terrier
et al., 2007). How the individual handles this event is likely influenced by, among
other factors, his/her self esteem. Therefore an examination of the putative
relationship between experiences of psychosis and levels of self-esteem may be
an important area for investigation, especially in very early stages of treatment.
We have previously reported (Vracotas et al., 2007) that distress experienced by
individuals suffering from a first episode of psychosis (FEP) is likely associated
with level of self-esteem, depression, and anxiety, but not with positive or
negative symptoms; and that level of self-esteem most likely mediates the
relationship between distress and the levels of depression and anxiety.
The primary objective of the present study was to investigate the role of selfesteem in influencing short term outcome in first-episode psychosis. We
hypothesize that the level of a patient’s self-esteem early in the course of
treatment of a first-episode psychosis will influence short term global outcome as
evaluated by the Global Assessment of Functioning (GAF; Spitzer et al., 1966)
measure at six months following initiation of treatment. A secondary hypothesis
35
was that self-esteem will influence symptom remission status at six months
following initiation of treatment.
METHOD
Setting
Subjects were recruited from the Prevention and Early Intervention Program for
Psychosis (PEPP) in Montreal, Quebec, Canada, a specialized service providing
assessment, treatment and follow-up to patients suffering from a FEP in one
sector of Montreal. There is no other competing service in this sector. Referrals
to PEPP were made from various services in the community including hospital
emergency services, community physicians and mental health service, educational
counselors, parents, police etc.).
Subjects
Criteria for admission to PEPP-Montreal include; age between 14 and 30 years,
DSM-IV-TR diagnosis of a psychotic disorder and not having received
antipsychotic medication for greater than one month. Patients with an IQ of < 70,
a diagnosis of organic brain syndrome or epilepsy are excluded. Primary
diagnosis of substance abuse/dependence is an exclusion criterion but concurrent
substance abuse with a primary diagnosis of psychotic disorder is not. All patients
provided an informed consent within the first month of entry to the program for
conducting all evaluations as part of a longitudinal study of outcome. For
participants under the age of 18 years, parental consent was obtained as well.
36
Consent forms and the assessment protocol had been approved by the institutional
human ethics board.
Measures
Diagnosis
DSM-IV-TR diagnosis was established with the Structured Clinical Interview for
DSM-IV-TR Axis I Disorders-Patient Edition (First et al., 2002) within the first 3
months of entry to the program and confirmed through consensus between two
senior psychiatrists and the interviewer.
Patient characteristics
The Topography of Psychotic Episode and the Circumstances of Onset and
Relapse Schedule, which include some material adapted from the Interview for
Retrospective Assessment of Onset of Schizophrenia (Häfner et al., 1992), were
administered during the first 3 months of treatment by research staff trained to
conduct these interviews. The information obtained includes basic demographic
characteristics and the time of onset of any psychiatric symptoms and the onset of
psychotic symptoms. Psychiatric symptoms occurring prior to onset of psychosis
refer to symptoms such as anxiety, depression, suicidal ideation and social
withdrawal (Norman, et al., 2005). Duration of untreated psychosis (DUP) was
calculated as the period beginning with the time of onset of psychotic symptoms
to the date of initiation of adequate antipsychotic treatment (Malla et al., 2002c;
Malla et al., 2006). Duration of untreated illness (DUI) was defined as the period
beginning with the first onset of any psychiatric symptoms to the time of adequate
37
antipsychotic medication. Adequate treatment was defined as taking antipsychotic medication for a period of one month or until significant response
whichever came first. Final ratings on DUP and DUI were arrived at through
consensus between the interviewer and at least two senior research-clinicians
based on a review of the information available.
Dependent variables
Outcome The Global Assessment of Functioning (GAF) scale was completed at
baseline and six months. The GAF is an ordinal scale (Range: 1 to 100) used to
rate the social, occupational and psychological functioning of patients and is
widely used in psychiatric research.
Remission of psychosis was defined as either total absence of psychotic symptoms
or at a level below that of threshold for psychosis. Patients were considered to
have achieved remission of positive symptoms if they showed either no evidence
or a mild level of psychotic symptoms (delusions, hallucinations, thought disorder
and bizarre behavior) lasting for at least 1 month, equivalent to a global rating of
2 or less on each of the global subscales on the SAPS.
Independent Variables
Symptoms Psychotic and negative symptoms were assessed at baseline with the
Scale for Assessment of Positive Symptoms (SAPS; Andreasen, 1984) and the
Scale for Assessment of Negative Symptoms (SANS; Andreasen, 1983),
respectively, whereas depression and anxiety were assessed with the Calgary
38
Depression Scale (CDS; Addington. 1992) and the Hamilton Anxiety Scale
(HAS; Riskind et al., 1987), respectively.
Pre-morbid functioning The Pre-morbid Adjustment Scale (PAS; Cannon-Spoor,
Potkin & Wyatt, 1982) was used to assess adjustment during childhood (up to age
11), early adolescence (11-15 years) and late adolescence (16-19 years) on social
and educational dimensions. We chose to include only the childhood and early
adolescence periods to avoid any possible overlap with onset of early symptoms.
The total score on the PAS was calculated by adding the scores on all items and
dividing by the total possible score. The final score is thus the proportion bound
between 0 (best possible) and 1 (worst possible). The same procedure was used
for each dimension and each period.
Self-esteem The Self-Esteem Rating Scale (SERS; Nugent & Thomas, 1993) was
administered within the first six months of treatment. The SERS is a 40-item selfrating scale with scores, which can range from -120 to 120, with higher scores
denoting higher and more positive self-esteem. The SERS has demonstrated high
reliability (coefficient alpha = 0.97) and good validity and has been validated in
individuals suffering from schizophrenia. It is suitable for use with English
(Nugent & Thomas, 1993) and French speaking populations (Lacomte, Corbiere,
& Laisne, 2006). The SERS includes statements that tap into multiple aspects
such as self-worth, social competence, problem-solving ability, intellectual
ability, self-competence, and basic worth compared to others.
The SERS was administered during the first six months following entry in the
program usually once patients were stable enough to complete a self-administered
39
instrument (mean = 3.37 weeks, SD = 10.08, Median = 1 week). As a sensitivity
test for stability of the measurement of self-esteem, we repeated the
administration of SERS within the six month period in a smaller sample (N=58)
of patients. We conducted a repeated measure analysis of variance to examine
change in self-esteem. We found that self-esteem is stable and does not improve
significantly from the time of entry (mean = 36.34; SD = 44.98) into the program
to six months (mean = 36.76; SD = 47.87) after treatment.
Data Analysis
Data analyses were conducted using the Statistical Package for Social Science for
Windows 11.5. Means, SD’s and frequencies were computed to summarize the
distribution of values for each variable. Pearson’s bi-variate correlations were
conducted between scores on the above mentioned scales on 121 subjects on
whom complete data were available. Then, a linear regression was conducted in
order to control for any possible covariates which have been shown in previous
studies to have an influence on outcome, such as, GAF at baseline, premorbid
adjustment, DUP, and gender. Finally, a logistic regression was conducted, with
remission status (a categorical variable) at six month following initiation of
treatment as the dependent variable, and self-esteem as the predictor variable.
40
RESULTS
One hundred and seventy six patients had completed six months of follow-up. Of
these 121 (68.75%) had completed the SERS. Of the rest, 20 returned incomplete
scales, and 35 refused or were unable to complete the scale.
The subjects were young (mean age = 23.27 years, SD = 4.02 with a mean of
11.82 years (SD = 2.38) years of education, predominantly single (n = 104, 86%),
male (n = 81, 66.9%), and with a diagnosis of a schizophrenia spectrum psychosis
(n = 96, 79.3%) or an affective psychosis (n = 25, 20.7%). Fifty-two percent of
individuals were outpatients at the time of entry to the program. The mean length
of illness duration from the time of first ever psychiatric symptoms (DUI) was
295.82 weeks (SD = 274.12; median = 219.29 weeks), and the mean DUP was
55.39 weeks (SD = 119.48; median = 17.57). Subjects with complete data (n =
121) on the SERS did not differ from those with no or incomplete data (n = 55) on
the following variables: age, gender, DUP, DUI, ratings of positive (SAPS) and
negative (SANS) symptoms, judgment and insight (PANSS item G-12),
depression (Calgary Depression Scale), and anxiety (Hamilton Anxiety Scale).
However, subjects with complete data were significantly (t = 3.265, p < .01) more
educated (mean = 11.83 years) than those with no or incomplete data (mean =
10.51 years).
At the time of entry into the program, the participants as a group exhibited
moderately low self-esteem (Mean = 33.95, SD = 44.42). A score of less than 43
is often regarded as indicative of a problematic degree of self-esteem (Nugent &
Thomas, 1993). As well, the participants exhibited a fairly low level of
41
functioning, according to GAF ratings (Mean = 29.66, SD = 7.27). As expected
there was a significant change (F = 226.436; p < .001) in GAF scores from
baseline (mean = 29.66; SD = 7.27) to six months (mean = 55.17; SD = 18.15).
Self-esteem and remission of psychosis
A logistic regression analysis was conducted, to investigate whether self-esteem
early on in the course of treatment had an effect on remission status at six months
following the initiation of treatment. Remission of psychosis was achieved by
about 67% (n = 81) of the sample at the end of six months of treatment (data was
missing for 2 individuals). The results showed that self-esteem did not influence
remission at six months (β = 0.003, p = .492).
Self-esteem and global functioning
Self-esteem was positively correlated with GAF at six months (r = 0.281, p <
.01). A linear regression analysis was conducted with GAF and depression (CDS)
at baseline, and gender, pre-morbid adjustment, DUP and self-esteem as
predictors, and GAF at six months as the outcome variable (Adjusted R 2 = 0.075;
p < .01). Only self-esteem at baseline was a significant predictor of GAF at six
months (β = 0.290, p = .004), after controlling for symptoms and functioning at
baseline, pre-morbid adjustment, gender, and duration of the untreated psychosis.
The scoring of GAF is likely influenced by a variety of symptoms. In order to
explore the influence that any particular symptom may have on the relationship
between functioning and self-esteem, we conducted a Pearson’s bi-variate
correlation matrix using SAPS, SANS, CDS, HAS at six months and SERS
42
scores. We found that negative and depressive symptoms were negatively related
to self-esteem scores (SANS, r = -.249, p < 0.01; CDS, r = -.256, p < 0.01),
whereas, positive symptoms and anxiety were not (SAPS, r = -.147, p > .05;
HAS, r = -.179, p > .05). However, when negative and depressive symptoms were
entered into a regression analysis with self-esteem as the dependent variable, only
depression at month six predicted level of self-esteem (β = -.254, p < .01). Given
that there is strong evidence that self-esteem may be associated with depression
we wanted to explore if indeed self-esteem, a stable characteristic in this sample,
was associated with depression at six months and, therefore, the association
between self-esteem and global functioning at six months might simply be a
reflection of concurrent depressive symptoms at six months. A regression
analysis was conducted to investigate this relationship, by entering depression at
month six as the dependent variable and depression at baseline as well as selfesteem as the independent variables. We found that self-esteem was not an
independent predictor of depression at month six when depression at baseline was
entered as a covariate (β = -.108, p > .05). Therefore, the relationship between
self-esteem and functional outcome is likely independent of depressive and
negative symptoms.
DISCUSSION
Self-esteem has recently been shown to hold significance in a wide range of
psychological states and is likely to be an important factor in influencing outcome
in psychiatric disorders. Consistent with our primary hypothesis, we found that
43
self-esteem is associated with short term (six months) global outcome as
measured by the Global Assessment of Functioning Scale even after controlling
for symptoms as well as functioning at the time of entry to treatment, pre-morbid
functioning, gender, and duration of untreated psychosis. This association,
although independent of the above confounds, appeared to be partially influenced
by level of concurrent depression but not any other symptoms. While both
concurrent negative and depressive symptoms appear to be influencing GAF
scores at six months, only depression had an independent effect on functioning.
The likely overlap between depression and negative symptoms may be explained
by the fact that rating of negative symptoms may reflect, at least in part,
depressive features. There is evidence to suggest that negative symptoms and
depression in schizophrenia are associated only when both ratings are observer
based and not when the level of depression is assessed with the use of selfadministered depression inventories (Norman & Malla, 1991).
Additionally, we were unable to show that self-esteem was associated with
remission of psychosis status at six months thus disconfirming our secondary
hypothesis. Considering that remission criteria rely on ratings of positive
symptoms, this is another indication that self-esteem is not associated with
positive symptoms. GAF on the other hand, is an outcome variable which takes
into account symptoms as well as various aspects of the functioning of the
individual. It appears, however, that it is in fact non-psychotic symptoms and
other aspects of functioning which are more likely associated with self-esteem.
One explanation for the above results may lay in the idea that a raised self-esteem
44
contributes ones self-concept, which is thought to be a mediating factor in
behaviour change (Littrell & Magel, 1991).
Our study has several strengths that improve its validity and clinical relevance.
First, it includes a sample of FEP patients from a defined catchment area with no
competing services, making the sample representative of the true incidence of
psychosis in this area. Second, subjects had little or no previous treatment and
were referred from both hospital emergency as well as community sources. Third,
our sample is very well characterized and no differences were observed between
patients who participated and those who refused or on whom complete data were
not available.
Limitations
It is important to note that this study is based on patients early on in treatment,
and therefore, as symptoms diminish further or stabilize these results may not
hold true.
It is equally possible that patients who did not participate in this study were in
someway different from those who did, even though in our sample patients who
refused to participate did not differ in symptom severity from those who did
participate. Another limitation to the current study is that the individuals in the
sample suffered from both affective (20.7%) and non-affective psychosis (79.3%).
It is possible that those who presented with an affective psychosis had different
levels of self-esteem and/or outcome scores which may have produced differential
results. Self-esteem may have a bigger role in affective psychosis but the
relatively small proportion of patients with affective psychosis did not allow a
45
separate analysis. Based on the correlational nature of this study, conclusions
regarding the causal role of self-esteem in determining outcome cannot be
assumed.
CONCLUSION
The results of the present study provide evidence to support the role of selfesteem in influencing outcome in early phases of psychosis. Given the influence
of self-esteem on global outcome and the lack of improvement in self-esteem over
a six-month course of treatment, there may be some value in introducing an
intervention to improve self-esteem, such as Cognitive behavioural therapy
interventions, which seem to be promising in their ability to raise self-esteem
(Hall & Terrier, 2002).
To our knowledge the study reported here is the first to examine the role of selfesteem in influencing outcome in first-episode psychosis. Future studies are
needed to evaluate further variables that may mediate the relationship between
outcome in first-episode psychosis and self-esteem. It may be possible that other
variable such as cognitive abilities, family and social support may influence this
relationship. As well, future research on this topic should aim to identify the
appropriate treatment that may have an effect in raising self-esteem early in the
course of a first-episode psychosis.
46
Funding and Support
This study was supported by a grant from the Canadian Institute of Health
Research (CIHR).
None of the authors have any conflict of interest, financial or otherwise, to
declare.
Acknowledgements
We acknowledge the assistance of the research staff of PEPP, Douglas Hospital
Research Centre, Montréal, Québec.
47
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CHAPTER 4: Manuscript 2
The Role of Early Life Experiences in determining Self-Esteem in Patients
with First-Episode Psychosis
Nadia Vracotas, MSc Candidate1; Ashok Malla, MBBS, FRCPC2
Prevention and Early Intervention Program for Psychosis (PEPP)
Douglas Mental Health University Institute
McGill University
6875 Boul. LaSalle, Montréal, Quebec, H4H 1R3, Canada
1
MSc candidate, McGill University, PEPP Montreal, Douglas Hospital Research
Centre, Montréal, Québec.
2
Professor of Psychiatry, McGill University, Montréal, Québec; Director,
Division of Clinical Research, Douglas Mental Health University Institute,
Montréal, Québec.
Corresponding author:
Ashok Malla
Professor, Department of Psychiatry,
Douglas Mental Health University Institute, McGill University,
6875 Boul. LaSalle, Montréal, Quebec, H4H 1R3, Canada
Office:1(514)761-6131 ext: 3418/3390
Fax:1(514)888-4064
[email protected]
52
ABSTRACT
Objectives: Low self-esteem seems to be related to a range of psychiatric
conditions, including psychotic disorders. Self-esteem is known to be influenced
by childhood experiences in the general population, however, little is known
about what factors influence level of self-esteem in psychosis. Early life
experiences such as parental care and protection as well as, neglect or abuse could
contribute to the development of self-esteem. Our aim was to investigate the
influence of early life experiences on the level of self-esteem in First-episode
psychosis (FEP).
Methods: The Self-Esteem Rating Scale, The Parental Bonding Instrument (PBI),
the Measure of Parental Style (MOPS) and The Childhood Trauma Questionnaire
(CTQ) were administered to 75 individuals with FEP receiving treatment at the
Prevention and Early Intervention Program for Psychoses in Montréal, Canada.
Symptoms and the Global Assessment of Functioning were assessed at entry to
the program and at six months.
Results: Self-esteem was negatively correlated with the PBI Overprotection (r = .317, p = .007), MOPS Overcontrol (r = -.281, p = .017) and MOPS Abuse (r = .262, p = .026) subscales, in relation to mothers. The only association for father
rated scales was with the MOPS indifference subscale (r = -.268, p = .031).
Additionally, self-esteem was negatively correlated with the CTQ Emotional
Neglect (r = -.295, p < .012), Emotional Abuse (r = -.413, p < .000) and Sexual
53
Abuse (r = -.261, p < .028) subscales. There was no association between selfesteem and physical neglect or abuse.
Conclusions: Better self-esteem is associated with lower levels of maternal
overprotection, overcontrol and abuse, and lower levels of paternal indifference.
Emotional neglect, emotional abuse and sexual abuse in childhood were found to
be associated with lower self-esteem in individuals with FEP. Interestingly,
physical neglect and abuse did not predict self-esteem. Both early life experiences
and self-esteem may be important to consider when assessing patients’ in FEP.
54
4.2. INTRODUCTION
It has been well established that the quality of early attachments and
parenting received has a direct and lifelong effect on psychological well-being
(Sato, et al. 1998; Thomasgard & Metz, 1996; Thomasgard & Metz, 1999). In
addition to early experience of relationships with parents other experiences both
within and around the family may also contribute to psychological health as
adults. Childhood trauma and maltreatment have been the subject of a
considerable amount of research in recent years. Some of these studies have
documented significant associations between negative childhood experiences and
mental health, physical health, and social outcomes (Sato, et al. 1998;
Thomasgard & Metz, 1996; Thomasgard & Metz, 1999; Browne & Finkelhor,
1986; Paz, Jones & Byrne, 2005; Read, van Os, Morrison & Ross, 2005). In
relation to mental health, associations have been made between childhood trauma
and adult depression (Parker, 1983; Parker, Kiloh & Hayward, 1987; Parker,
1993), anxiety disorders, eating disorders, substance misuse and abuse, posttraumatic stress disorder, sexual dysfunction, aggressive behaviours, personality
disorders (Crouch & Milner, 1993; Kendall-Tackett, Williams, Finkelhor, &
1993; Knutson, 1995; Malinosky-Rummell & Hensen, 1993), and suicidal
behaviour (Terrier, Khan, Cater, & Picken, 2007). More recently, large-scale
population studies have also linked early life abuse and maltreatment to increased
risk for psychosis (Spataro, Mullen, Burgess, Wells, & Moss, 2004; Bebbington et
al., 2004; Janssen et al., 2004; Whitfield, Dube, Felitti, & Anda, 2005). In a
review of five major studies Larkin and Read (2008) examined the hypothesis that
childhood trauma increases the risk for psychotic experience. They concluded that
55
there was indeed a significant dose effect. Specifically, the number of traumas
experienced was related to an increase risk of psychosis. The studies reviewed
involved large samples, including one prospective study, and they all controlled
for potential confounding variables.
Low self-esteem also seems to be an important concept in the
understanding and treatment of a wide range of psychiatric conditions
(Silverstone, 1991; Markowitz, 2001; Bardone, Vohs, Abramson, Heaatherton, &
Joiner, 2000; Roberts & Monroe, 1994; Clarke & Kissane, 2002; DuBois & Flay,
2004; Elmer, 2001), including psychotic disorders (Freeman et al., 1998;
Bradshaw & Brekke, 1999; Roe, 2003; Bowins & Shugar, 1998). In fact, selfesteem has repeatedly been implicated in the formation (Kinderman & Bentall,
1996; Colby, 1977) and the maintenance of delusions (Bowins & Shugar, 1998)
and hallucinations (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001).
Bentall and colleagues have proposed that paranoid delusions result from attempts
to maintain self-esteem in individuals with underlying low self-worth (Bental,
Kinderman, & Kaney, 1994; Kinderman & Bentall, 1996; Bentall & Kaney,
1996). We have previously reported that distress experienced by individuals
suffering from a first-episode of psychosis (FEP) is likely associated with level of
self-esteem, depression, and anxiety, but not with positive or negative symptoms;
and that level of self-esteem most likely mediates the relationship between
distress and the levels of depression and anxiety (Vracotas et al., Chapter 3). More
recently, we found that higher self-esteem was associated with a more favorable
short term global outcome after six month of treatment for a FEP (Vracotas et al.,
submitted).
56
While a number of studies have shown associations between level of self-esteem
and different aspects of psychotic disorders, little is known about what factors
influence the level of self-esteem in patients with FEP.
Studies conducted with general population samples been able to have
found an association between perceived parental rearing styles and level of selfesteem (Miller, Warner, Wickramaratne, & Weissman, 1999). Others have
concluded that level of maltreatment suffered in the past may influence future
levels of self-esteem (Bolger, Patterson & Kupersmidt, 1998). Based on the
evidence reported above, it is likely that early life experiences such as parenting
styles, abuse and neglect also contribute to a person’s self concept and, therefore,
affect the level of self-esteem in patients who present for treatment of a firstepisode of psychosis. Therefore, an examination of the putative relationship
between levels of self-esteem and early life experiences may be an important area
for investigation, especially in very early stages of treatment.
Our aim was to investigate the influence of early life experiences including
perceived parenting styles on the level of self-esteem in a FEP sample.
4.3. METHOD
Setting
Subjects were recruited from the Prevention and Early Intervention
Program for Psychosis (PEPP) in Montréal, Québec, Canada. PEPP is a
specialized service providing assessment, treatment and follow-up to patients
suffering from a FEP in one sector of Montréal. There are no other competing
57
services in this sector. Referrals to PEPP are made from various services in the
community including hospital emergency services, community physicians and
mental health service, educational counselors, parents, police etc.
Subjects
Criteria for admission to PEPP-Montréal include; age between 14 and 30
years old, DSM-IV-TR diagnosis of a psychotic disorder and not having received
antipsychotic medication for greater than one month. Patients with an IQ of < 70,
a diagnosis of organic brain syndrome or epilepsy are excluded. Primary
diagnosis of substance abuse/dependence is an exclusion criterion however,
concurrent substance abuse with a primary diagnosis of psychotic disorder is not.
All patients provided an informed consent within the first month of entry to the
program for conducting all evaluations as part of a longitudinal study of outcome.
For participants under the age of 18 years old, parental consent was obtained as
well. Consent forms and the assessment protocol had been approved by the
institutional human ethics board. Clients were approached to complete
assessments and consent only when they were stable enough to fully understand
what was being asked of them.
Measures
Diagnosis
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR,
American Psychiatric Association, 2000) diagnosis was established with the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition
58
(First, Spitzer, Gibbon, & Williams, 2002) within the first 3 months of entry to the
program and confirmed through consensus between two senior psychiatrists and
the interviewer. Patients are categorized as having either a schizophrenia
spectrum disorder, which includes schizophrenia (Paranoid type, disorganized
type, catatonic type, undifferentiated type, and residual type), schizophreniform
disorder, schizoaffective disorder and delusional disorder or an affective
psychosis which include major depression disorder with psychotic features,
bipolar disorder with psychotic feature, and mania with psychotic features.
Patient characteristics
The Topography of Psychotic Episode and the Circumstances of Onset and
Relapse Schedule, which include some material adapted from the Interview for
Retrospective Assessment of Onset of Schizophrenia (Häfner et al. 1992), were
administered during the first 3 months of treatment by research staff trained to
conduct these interviews. The information obtained includes basic demographic
characteristics and the time of onset of any psychiatric symptoms and the onset of
psychotic symptoms. Psychiatric symptoms occurring prior to onset of psychosis
refer to symptoms such as anxiety, depression, suicidal ideation and social
withdrawal (Norman, et al., 2005). Duration of untreated psychosis (DUP) was
calculated as the period beginning with the time of onset of psychotic symptoms
to the date of initiation of adequate antipsychotic treatment (Malla et al., 2002;
Malla et al., 2006). Duration of untreated illness (DUI) was defined as the period
beginning with the first onset of any psychiatric symptoms to the time of adequate
antipsychotic medication. Adequate treatment was defined as taking antipsychotic
59
medication for a period of one month or until significant response whichever
came first. Final ratings on DUP and DUI were arrived at through consensus
between the interviewer and at least two senior research-clinicians based on a
review of the information available.
Dependent variables
Self-esteem The Self-Esteem Rating Scale (SERS; Nugent & Thomas, 1993) was
administered during the first six months following entry in the program usually
once patients were stable enough to complete a self-administered instrument
(mean = 3.37 weeks, SD = 10.08, Median = 1 week). The SERS is a 40-item selfrating scale with scores, which can range from -120 to 120, with higher scores
denoting higher and more positive self-esteem. The SERS has demonstrated high
reliability (coefficient alpha = 0.97) and good validity and has been validated in
individuals suffering from schizophrenia. It is suitable for use with English
(Nugent & Thomas, 1993) and French speaking populations (Lacomte, Corbiere
& Laisne, 2006). The SERS includes statements that tap into multiple aspects
such as self-worth, social competence, problem-solving ability, intellectual
ability, self-competence, and basic worth compared to others.
As a sensitivity test for stability of the measurement of self-esteem, we repeated
the administration of SERS within the six month period in a sample (N=58) of
patients. A repeated measure analysis of variance to examine change in selfesteem revealed that self-esteem is stable and does not change significantly from
the time of entry (mean = 36.34; SD = 44.98) into the program to six months
(mean = 36.76; SD = 47.87) after treatment.
60
Independent Variables
Perception of childhood experience was measured using The Parental Bonding
Instrument (PBI; Parker, Tupling & Brown, 1979) and the Measure of Parental
Style instrument (MOPS; Parker et al., 1997). The PBI and the MOPS are
measures of perceived quality of received parenting during the respondents’ first
16 years of life. The PBI is a 25-item scale and the MOPS is a 15-item scale.
Both scales are rated on a likert scale from 0 to 3. Items on the PBI are arranged
such that some questions are asked in the negative, and, therefore, have to be
transformed, giving a rage of 0-39 for the protection scale and 0-36 for the care
scale, with higher scores indicating greater care and protection. The MOPS yields
three subscales: Indifference, Abuse, and Overcontrol. The total score for each
subscale denotes the degree to which the parental style was experienced by the
individual: with higher scores indicating greater indifference, abuse and
overcontrol. The PBI and the MOPS are rated separately for both mothers and
fathers.
Childhood Trauma was assessed using The Childhood Trauma Questionnaire
(CTQ; Bernstein & Fink, 1994), a 28-item self-report retrospective inventory
designed to measure childhood or adolescent abuse and neglect. Individuals were
asked to take into consideration the first 16 years of their life to remain consistent
with the PBI and MOPS. The CTQ contains five subscales, three assessing abuse
(Emotional, Physical, and Sexual), and two assessing neglect (Emotional and
Physical). Five items are assigned to each subscale and the three remaining items
form the Minimization-Denial subscale to account for extreme response bias. The
61
items are arranged on a 5-point Likert scale from 1 to 5, which corresponds to
never true to very often true. Therefore, each subscale score ranges from no
history of abuse (5) to very extreme history of abuse or neglect (25).
Data Analysis
Data were analyzed using the Statistical Package for Social Science
(SPSS) for Windows 15.0. Means, SD’s and frequencies were computed to
summarize the distribution of values for each variable.
Given the skewed distribution for data on all subscales of the MOPS and
CTQ, Spearman’s bivariate correlations were conducted between scores on
subscale scores from the PBI, MOPS, and CTQ on 75 subjects on whom complete
data were available. Then, we conducted a stepwise regression analyses to
evaluate the independent contribution of each of the predictor variables (subscales
of PBI, MOPS, and CTQ) which had shown significant bivariate correlations.
With Self-esteem as the dependent variable, we first entered the predictor variable
shown to elicit the strongest relationship with the dependent variable. Subsequent
models were added according to additional predictor variables which had
previously elicited a correlation.
In order to control for any possible covariates that have been shown in
previous studies to have an influence on self-esteem, such as depression, anxiety,
and negative symptom, another regression analysis was conducted including any
subscale of the PBI, MOPS or CTQ that remained significant after the previous
regression analysis.
62
4.4. RESULTS
We previously reported results of a study on self-esteem and its influence
on short term outcome in 121 patients. Out of these, we were able to approach 82
individuals to participate in the current study. Seven (8.5%) refused to participate.
The remaining 39 of the original sample (n = 121) had finished their follow up at
the clinic and we were unable to contact them.
The subjects (N=75) were young (mean age = 22.75 years, SD = 3.94 with
a mean of 11.79 years (SD = 2.13) years of education, predominantly single (n =
68, 90.7%), male (n = 45, 60%), and had a diagnosis of a schizophrenia spectrum
psychosis (n = 55, 73.3%) or an affective psychosis (n = 20, 26.7%). Thirty-eight
(50.7%) individuals were outpatients at the time of entry to the program. The
length of illness duration from the time of first ever psychiatric symptoms (DUI)
was 233.86 (median) weeks (mean = 296.44; SD = 261.74), and the DUP was
16.20 (median) weeks (mean = 56.57; SD = 134.80).
Subjects who agreed to participate in the study (n = 75) did not differ from
those who where not approached (n = 39) or refused to participate in the study (n
= 7) on the following variables: age, gender, education, DUP, DUI, ratings of
negative (SANS) symptoms, judgment and insight (PANSS item G-12),
depression (Calgary Depression Scale), anxiety (Hamilton Anxiety Scale),
functioning at month 6 and self-esteem (Self-Esteem Rating Scale). However,
subjects who participated reported significantly greater positive symptoms (SAPS
global) at baseline (mean = 12.27, SD = 3.09; and mean = 10.64, SD = 3.16,
respectively, t = 3.347, p < .01) and lower functioning (Global Assessment of
Functioning Scale; participants: mean = 27.96, SD = 6.76; non-participants: mean
63
= 30.89, SD = 7.30, respectively, t = -2.785, p < .01) than those who did not
participate in the study. At the time of entry into the program, the participants as a
group exhibited moderately low self-esteem (Mean = 38.23, SD = 45.48, Median
= 46.50).
Self-esteem and parental bonding and style
Self-esteem was negatively correlated with the PBI Overprotection (r = .317, p = .007), MOPS Overcontrol (r = -.281, p = .017) and MOPS Abuse (r = .262, p = .026) subscales, in relation to mothers. The only association for father
rated scales was with the MOPS indifference subscale (r = -.268, p = .031).
Self-esteem and childhood trauma
Self-esteem was negatively correlated with the CTQ Emotional Neglect (r
= -.295, p < .012), Emotional Abuse (r = -.413, p< .000) and Sexual Abuse (r = .261, p < .028) subscales. There was no association between self-esteem and
physical neglect or abuse subscales.
Self-esteem and early life experiences
Based on the considerable overlap observed (refer to Table 1) in the
relationship between subscales from the PBI, MOPS and CTQ we conducted a
stepwise (Enter) hierarchical regression to assess the relative importance of the
independent variables in predicting self-esteem. The scores on the SERS were
entered as the dependent variable. For independent variables Emotional Abuse
(CTQ) was entered first, followed by maternal Overprotection (PBI), Emotional
64
Neglect (CTQ), maternal Overcontrol (MOPS), maternal Abuse (MOPS), Sexual
Abuse (CTQ), and finally paternal Indifference (MOPS). Emotional Abuse (CTQ)
remained a significant predictor of self-esteem, contributing 26.5% of the
variance explained whereas maternal Overprotection, Emotional Neglect,
maternal Overcontrol, maternal Abuse, Sexual Abuse, and paternal Indifference
made limited additional significant contribution to the model, only contributing
3.5%, 0.1%, 0.4%, 4.3%, 2.6% and 0.6%, respectively of variance to the model
(Table 2).
Thirty-eight percent of the variance in self-esteem reported by individuals
suffering from a FEP early on in treatment is explained by a model incorporating
emotional abuse and neglect, sexual abuse, maternal overprotection, overcontrol
and abuse, and paternal Indifference.
Previous studies have found that state variables are likely to influence selfesteem (Silverstone, 1991). We conducted Spearman’s bivariate correlations
between self-esteem, depression, anxiety and negative and positive symptoms at
baseline. We found that depression (r = -.435, p < .001), anxiety (r = -.405, p <
.001) and negative (r = -.263, p < .05) symptoms were negatively associated with
self-esteem, whereas, positive symptoms failed to show any association.
Therefore, in order to control for these covariates, we entered depression, anxiety,
and negative symptoms into a stepwise regression analysis after Emotional Abuse
subscale from the CTQ, with self-esteem as the dependant variable. Emotional
Abuse (CTQ) remained a significant predictor of self-esteem (ß = -.485, p < .001),
whereas, depression, anxiety and negative symptoms were no longer significant.
65
4.5. DISCUSSION
While there have been many studies examining the effects of parental
attachment styles, trauma, and neglect on future psychological well-being, little
research has focused on these variables and their effect on self-esteem later on in
life. As well, virtually no studies have had the opportunity to examine this
question on a FEP, which is a population relatively naïve to most forms of
intervention. Self-esteem has been shown to hold significance in a wide range of
psychological states (Clarke & Kissane, 2002; DuBois & Flay, 2004; Elmer,
2001) and is likely to be an important factor in influencing outcome in psychiatric
disorders (Silverstone, 1991; Markowitz, 2001; Bardone et al., 2000; Roberts &
Monroe, 1994), including psychotic disorders (Vracotas et al., chapter 3.). Our
findings reported here show that lower self-esteem is associated with some
aspects of early life experiences, specifically, emotional abuse and to a lesser
extent emotional neglect and sexual abuse in childhood in individuals with FEP.
Interestingly, physical neglect and abuse did not predict self-esteem. Given that
our operational definition of self-esteem was ‘confidence in one’s own worth or
abilities’, one could imagine that years of emotional abuse which may brake down
a child’s perception of their self-worth, during critical stages of development.
Therefore, the child grows up not believing in them self and their own abilities.
Additionally, we found that better self-esteem is associated to a modest
degree with lower levels of maternal overprotection, overcontrol and abuse, as
well as, lower levels of paternal indifference. Multivariate analysis also revealed
that emotional abuse is the most significant variable associated with lower self66
esteem. However, the high correlation (Table 1) between emotional abuse and
most of the subscales of PBI (mother and father Care, and mother Overprotection
subscales) and MOPS (mother and father Indifference, Abuse, and Overcontrol
subscales) would imply that these variables may also have an influence on selfesteem.
Our study has several strengths, which improve its validity and clinical
relevance. First, it includes a sample of FEP patients derived from a cohort of
new cases from a defined catchment area with no competing services. Second,
given the fact that the sample only includes FEP patients, the subjects had little or
no previous treatment and were referred from both hospital emergency as well as
community sources. Third, our sample is very well characterized and few
differences were observed between patients who participated and those who
refused or were not approached to participate. The subjects included in the study
were somewhat more symptomatic than those not included, however, this is
unlikely to have influenced the results reported in the direction observed.
Limitations of the study include the possibility that patients who were no
longer being followed and therefore were not approached or refused to participate
in this study were different in ways that we were not able to assess and therefore,
conclusions can not be assumed for every individual suffering from a FEP.
Another limitation to the current study is that the individuals in the sample
suffered from both affective (23.7%) and non-affective psychosis (73.3%). We
conducted an independent sample t-test to examine the possibility of the two
groups being somewhat different on levels of self-esteem as well as their
67
perceptions of early life experiences. We found that the non-affective psychosis
(mean = 31.48, SD = 42.9) group had a significantly lower self-esteem than the
affective psychosis (mean = 56.45, SD = 48.1) group (t = -2.149, p <0.05), as
well, the non-affective psychosis (mean = 3.44, SD = 3.1) group perceived their
fathers as being more over controlling than the affective psychosis (mean = 1.56,
SD = 1.6) group (t = 3.133, p < .01). However, it is unlikely the differences in
absolute levels of self-esteem between the two groups would have influenced
association between independent variables (childhood experiences) and selfesteem. Further, the two groups were unequal in size, and therefore, findings
should be interpreted with caution. Based on the correlational nature of this study,
conclusions regarding the causal role early life events in determining self-esteem
cannot be assumed.
4.6. CONCLUSION
The results of the present study provide evidence to support the role of
early life events in influencing self-esteem in early phases of psychosis.
Particularly, emotional abuse experienced before the age of 16 years old seems to
have the most salience in influencing an individual’s level of self-esteem early on
in the treatment of a FEP. Given the association reported between self-esteem and
functional outcome these findings have some relevance in understanding the
source of lower self-esteem in patients with psychotic disorders. More effort
should be made to assess patients’ early life experiences and its effects on selfesteem and to provide specialized interventions that address these issues.
68
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73
PBI
MOPS
Emotional Abuse
Emotional Neglect
Physical Abuse
Physical Neglect
Overcontrol (F)
Overcontrol (M)
Abuse (F)
Abuse (M)
Indifference (F)
Indifference (M)
Overprotection (F)
Overprotection (M)
Care (F)
Care (M)
Care (M)
1
Care (F)
,442***
1
1
-,230
-,483***
Overprotection (M)
Overprotection (F)
1
,220
-,445***
-,154
Indifference (M)
1
,127
,345**
-,337**
- ,713***
Indifference (F)
1
,445***
,135
,159
-,659***
-,360**
1
,489***
,727***
,236
,480***
-,443***
-,674***
Abuse (F)
1
,391**
,565***
,333**
,646***
,206
-,623***
-,227
MOPS
Abuse (M)
PBI
Overcontrol (M)
1
,251*
,545***
,394**
,511***
,062
,736***
-,301*
-,554***
Overcontrol (F)
1
,416**
,684***
,356**
,356**
,382**
,587***
,174
-,408**
-,195
Physical Neglect
1
,005
,167
,216
,310**
,276*
,299*
,156
,141
-,251*
-,293*
Physical Abuse
1
,007
,178
,162
,318*
,213
,303*
-,023
,289*
,246*
-,366**
-,049
CTQ
1
,249*
,541***
,115
,310**
,416**
,552***
,553***
,496***
,280*
,302*
-,635***
-,580***
Emotional Neglect
Table 1. Spearman's rho Correlation Coefficients (N = 75)
1
,657***
,313**
,322*
,406**
,575***
,484***
,676***
,661***
,519***
,182
,471***
-,521***
-,484***
Emotional Abuse
,249*
,338**
,120
,356**
,078
,047
,306*
,227
,328**
,197
,252*
,052*
-,287*
-,292*
Sexual Abuse
1
Note. PBI = Parental Bonding Instrument; MOPS = Measure of Parental Style; CTQ = Childhood Trauma Questionnaire; F = Father; M = Mother. * p < 0,05, ** p < 0,01, *** p < 0,001.
CTQ
Sexual Abuse
EA(CTQ)
EA(CTQ)+OP(mPBI)
EA(CTQ)+OP(mPBI)+EA(CTQ)
EA(CTQ)+OP(mPBI)+EA(CTQ)+OC(mMOPS)
EA(CTQ)+OP(mPBI)+EA(CTQ)+OC(mMOPS)+A(mMOPS)
EA(CTQ)+OP(mPBI)+EA(CTQ)+OC(mMOPS)+A(mMOPS)+SA(CTQ)
EA(CTQ)+OP(MPBI)+EA(CTQ)+OC(MMOPS)+A(MMOPS)+SA(CTQ)+I(fMOPS)
Model
0.265
0.299
0.301
0.305
0.348
0.374
0,380
R²
0.265
0,035
0.001
0.004
0.043
0.026
0.006
R² change
75
0,000
0.093
0.733
0,548
0.061
0.137
0.482
Sig. F
Note. SERS = Self-Esteem Rating Scale; CTQ = Childhood Trauma Questionnaire (EA = Emotional Abuse; EN = Emotional Neglect; SA = Sexual Abuse); mPBI = mother version
of Parental Bonding Instrument (OP = Overprotection); mMOPS = mother version of Measure of Parental Style (OC = Overcontrol; A = Abuse); fMOPS = father version of Measure
of Parental Style (I = Indifference).
SERS
Dependent
Variable
Table 2. Hierarchical regression model for predictors of Self-Esteem (N = 62)
CHAPTER 5
5.1. DISCUSSION
Over the past decade there has been an increased interest in the investigation of
self-esteem in relation to those who suffer from severe mental illness. Self-esteem
has recently been shown to be a significant influence in a wide range of
psychological states and has also been linked to psychosis. Among some of the
findings in psychosis research, are the link between self-esteem and social
functioning (Brashaw & Brekke, 1999; Roe, 2003), perceived quality of life
(Eklund et al., 2003; Torrey et al., 2000), depression (Shahar & Davidson, 2003),
subjective distress (Vracotas et al., 2007) and psychotic symptoms (Barrowclough
et al., 2003; Shahar & Davidson, 2003). We proposed that self-esteem is likely to
be an important factor in influencing outcome in psychotric disorders. Consistent
with our primary hypothesis, we found that self-esteem is associated with short
term (six months) global outcome as measured by the Global Assessment of
Functioning Scale even after controlling for symptoms as well as functioning at
the time of entry to treatment, pre-morbid functioning, gender, and duration of
untreated psychosis. These latter factors are well known to influence outcome.
This association, although independent of the above confounds, appeared to be
partially influenced by level of concurrent depression but not any other
symptoms. While both concurrent negative and depressive symptoms appear to be
influencing GAF scores at six months, only depression had an independent effect
on functioning. The likely overlap between depression and negative symptoms
may be explained by the fact that rating of negative symptoms may reflect, at least
in part, depressive features. There is evidence to suggest that negative symptoms
and depression in schizophrenia are associated only when both ratings are
observer based and not when the level of depression is assessed with the use of
self-administered depression inventories (Norman & Malla, 1991). On the other
hand, we were unable to show an association between self-esteem and remission
of psychosis at six months. Considering that our remission criteria rely on ratings
of positive symptoms, this is another indication that self-esteem is not associated
with positive symptoms. GAF on the other hand, is an outcome variable which
takes into account a variety of symptoms as well as various aspects of the
individual’s functioning. It appears, however, that it is in fact non-psychotic
symptoms and other aspects of functioning which are more likely associated with
self-esteem.
Self-esteem on the other hand may be associated with early life experiences such
as parental care and attachment or abuse and neglect. It has been well established
that the quality of parenting received has direct and lifelong effects on
psychological well-being (Sato, et al. 1998; Thomasgard & Metz, 1996;
Thomasgard & Metz, 1999). In line with our secondary hypotheses, we were able
to show that lower self-esteem is associated with some aspects of negative early
life experiences, specifically, emotional abuse and to a lesser extent emotional
neglect and sexual abuse in childhood in individuals with FEP. Interestingly,
physical neglect and abuse did not predict self-esteem. Additionally, we found
that better self-esteem is associated to a modest degree with lower levels of
maternal overprotection, overcontrol and abuse, as well as, lower levels of
77
paternal indifference. Multivariate analysis also revealed that emotional abuse is
the most significant variable associated with lower self-esteem. However, the high
correlation between emotional abuse and most of the subscales of PBI (mother
and father Care, and mother Overprotection subscales) and MOPS (mother and
father Indifference, Abuse, and Overcontrol subscales) would imply that these
variables may also have an influence on self-esteem but overlap with emotional
abuse.
Our studies have several methodological strengths that improve its validity and
clinical relevance. First, the sample for this study is derived from a larger sample
of FEP patients from a defined catchment area with no competing services,
making the sample representative of the treated incidence cases of psychosis in
this area. Additionally, in the first study there were no significant differences
between those who participated and those who did not. However, in the second
study subjects who participated reported significantly greater positive symptoms
(SAPS global) at baseline and lower global functioning (GAF) than those who did
not participate in the study. The discrepancy in symptomatology between groups
would unlikely have influenced the results reported in the direction observed.
Second, subjects had little or no previous treatment and were referred from both
hospital emergency as well as community sources. Prospective studies of
previously untreated patients with psychotic disorders have the advantage of not
selectively recruiting poor outcome patients, examining outcome prospectively
and avoiding confound of long periods of pharmacological treatment and periods
of hospitalizations. Third, the first study included both a clinical and a functional
78
dimension as our outcome variables, as Strauss & Carpenter (1977) have stated
that these two dimensions may be relatively independent of each other. Fourth,
the second study examined perceived parental styles, by both parents individually,
as well as trauma that may have been experienced from someone other than a
parent or a caregiver. As it is sometimes the case that abuse or neglect goes
unreported due to the specificity of questions. Finally, to our knowledge this is the
first study to examine these two issues in psychotic disorders.
It is important to note that these studies are based on patient’s early on in
treatment, and therefore, as symptoms diminish further or stabilize, these results
may not hold true.
It is equally possible that patients who did not participate in this study were in
someway different from those who did participate beyond the observed difference
in symptomatology (study #2), in ways we were not able to assess and therefore,
conclusions can not be generalized to all individuals suffering from a FEP.
Another limitation is that the individuals in these studies suffered from both
affective (20.7%; 23.7%, respectively) and non-affective psychosis (79.3%;
73.3%, respectively). We conducted an independent sample t-test on the second
sample. We performed a sensitivity analysis to examine the possibility of the two
groups being somewhat different on levels of self-esteem or on their perceptions
of early life experiences. We found that the non-affective psychosis group had a
significantly lower self-esteem than the affective psychosis group, as well, the
non-affective psychosis group perceived their fathers as being more
overcontrolling than the affective psychosis group. However, it is unlikely the
79
differences in absolute levels of self-esteem between the two groups would have
influenced association between independent variables (childhood experiences)
and self-esteem. Further, the two groups were unequal in size, and therefore,
findings should be interpreted with caution.
Based on the correlational nature of these studies, conclusions regarding the
causal role of self-esteem in determining outcome as well as, conclusions
regarding the role early life events have in determining self-esteem cannot be
assumed.
Based on the current findings it seems fundamentally important to routinely assess
young individuals entering a treatment program for a FEP, for their level of selfesteem, past childhood experiences and trauma. Histories of abuse and neglect are
common among individuals who experience mental health problems, and unless
they are routinely assessed they are likely to go undetected by treatment
professionals. For example, a study by Briere & Zaidi (1989) reported that when
emergency personnel are trained in systematic interviewing techniques
specifically aimed at identification of past traumas, the rate at proper
identification of past sexual abuse in adult female patients rose from 6% to 70%.
Our growing understanding of the pathways by which past experience may
influence certain relatively stable characteristics such as self-esteem which may
then influence outcome in disorders such as psychosis can form part of an
integrative approach to the conceptualization of psychotic disorders, their
assessment and treatment. Therefore, further studies need to be conducted to
further our understanding of how early life experiences interact with other
vulnerabilities to determine onset and outcome of psychotic disorders.
80
5.2. CONCLUSION
The results of the present study provide evidence to support the role of early life
events in influencing self-esteem, and subsequently the role of self-esteem in
influencing outcome in early phases of psychosis. Particularly, emotional abuse
experienced before the age of 16 years seems to have the most salience in
influencing an individual’s level of self-esteem in patients being treated for FEP.
Given the relatively low self-esteem reported by a substantial proportion of
patients with psychotic disorders, influence of self-esteem on global outcome and
the relative stability of self-esteem over time as suggested by lack of improvement
over a six-month course of treatment, these findings have some relevance in
understanding the source of lower self-esteem in patients with psychotic
disorders. More effort should be made to assess patients’ early life experiences
and its effects on self-esteem and to provide specialized interventions that address
these issues. There may be value in introducing an intervention to improve selfesteem, such as cognitive remediation therapy (Wykes et al., 2003), cognitive
behavioral therapy (Hall & Terrier, 2003) or training in improving social and
functioning skills, which seem to be promising in their ability to raise self-esteem.
Cognitive beahavioural therapy has also been shown to significantly reduce
psychotic symptoms (Haddock et al., 1998; Rector & Beck, 2001) and is therefore
an ideal form of treatment in this population.
81
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90
APPENDIX A:
• Consent form
• Assent form
91
Outcome in First-Episode Psychosis:
The Role of Self-Esteem, Parental Bonding, Abuse and Neglect
Investigators: Ashok Malla M.D.
Nadia Vracotas (M.Sc Candidate)
CONSENT FORM
REASON FOR THE STUDY
The purpose of the present study is to explore perceptions of parental care
and attachment styles, as well as trauma which you may have
experienced before the age of 16 years old and its relationship to selfesteem.
WHO CAN PARTICIPATE IN THE STUDY?
In order to participate in this study, you must be part of the PEPP program.
INFORMED CONSENT
Prior to any procedure related to this study, you will be asked to read this
consent form. You will be given enough time to ask any questions. If you
decide to participate you will be asked to sign this consent form. You can
withdraw your consent at any time without any impact on you or your
future treatment at PEPP.
STUDY PROTOCOL
If you decide to participate, you will be asked to complete two
questionnaires:
The parental Bonding Instrument, the Measure of Parenting Style and the
Childhood Trauma Questionnaire. These three questionnaires will ask you
questions about your memory of your relationship with your parents before
the age of 16. The questionnaires take about 10 minutes to be completed.
ACCESS TO MEDICAL FILE
We also ask your permission to access your clinical chart at the PEPP
Program, Douglas Mental Health University Institute. We will do this to
assess how well you are doing, the treatment you are receiving and the
symptoms that you may be experiencing. All information will be treated as
confidential (see confidentiality section below).
92
RISKS AND BENEFITS
Although there is no direct benefit for participating in this study, we assure
you that the information that you provide will help us improve services for
people experiencing a first episode of psychosis.
CONFIDENTIAL NATURE OF THIS STUDY
This project is confidential, which means that only individuals associated
with the study will have access to your information, unless otherwise
specified by law, and all information will be coded and kept in a drawer of
a locked filing cabinet at PEPP-Montreal of the Douglas Mental Health
University Institute under the supervision of Dr. Ashok Malla.
All data will be destroyed 10 years after the study has been completed. No
personal information will be released to third parties without your written
approval unless required by law. By signing this consent form, you are not
giving up any of your rights.
WITHDRAWAL FROM THE STUDY
Your participation in this study is voluntary, and your decision to
participate in this project, or to withdraw from the study at any time, will
have no consequences on the clinical services that you or your family
members may receive now or in the future.
COMPENSATION FOR PARTICIPATION IN THE STUDY
We will compensate you for parking and transportation for the extra visits
you will make for assessments related to participation in this study.
WHO CAN I TALK TO IF I HAVE ANY QUESTIONS ABOUT THIS
STUDY?
You can always contact any of the investigators at 761-6131 (extension
3418 for Dr. Ashok Malla, extension 2405 for Nadia Vracotas). If you have
any questions regarding your rights, you can contact the Douglas Mental
Health University lnstitute Ombudsman at 761-6131 extension 3287.
93
SIGNATURE
I have read and understood this consent form. I have been given sufficient
time and opportunity to ask questions. This study has been explained to
my satisfaction and all of my questions related to the study protocol have
been answered. I have been informed about the possible benefits and
risks related to my participation in the study and my questions have been
answered to my satisfaction. I understand that participation in this study is
voluntary and that I may withdraw from the study at any time and if I
withdraw, it will not affect the future care and attention which I will receive
from my doctors and my treatment team.
 By
signing and dating this consent form, I freely and voluntarily
agree to participate in this study. I will receive a copy of this signed
and dated informed consent form.
 I grant permission to place a copy of my consent form in my
hospital file. A copy of the informed consent form can be placed in
your Douglas Mental Health University Institute medical file to
facilitate communication between clinicians during your visits to the
hospital.
 I allow individuals associated with this study to consult my medical
file. They may consult my medical file to get information about my
symptoms and my treatment relevant to my participation in this
study.
NAME _____________________________________________________
DATE OF BIRTH
_____/___/_____ (dd/mm/yyyy)
SIGNATURE ________________________________________________
PARTICIPANT
DATE
CONTACT NO.
I confirm that I have explained the nature of the study as well as any
potential risks and benefits to the participant whose name and signature
appears above.
NAME ____________________________________________________
SIGNATURE_______________________________________________
RESEARCH ASSISTANT
DATE
CONTACT NO.
94
Outcome in First-Episode Psychosis:
The Role of Self-Esteem, Parental Bonding, Abuse and Neglect
Investigators:
Ashok Malla M.D.
Nadia Vracotas (MSc. Candidate)
ASSENT FORM
REASON FOR THE STUDY
The purpose of the present study is to explore perceptions of parental care
and attachment styles, as well as trauma which you may have
experienced before the age of 16 years old and its relationship to selfesteem.
WHO CAN PARTICIPATE IN THE STUDY?
In order to participate in this study, you must be part of the PEPP program.
INFORMED CONSENT
Prior to any procedure related to this study, you will be asked to read this
consent form. You will be given enough time to ask any questions. If you
decide to participate you will be asked to sign this consent form. You can
withdraw your consent at any time without any impact on you or your
future treatment at PEPP.
STUDY PROTOCOL
If you decide to participate, you will be asked to complete two
questionnaires:
The parental Bonding Instrument, the Measure of Parenting Style and the
Childhood Trauma Questionnaire. These three questionnaires will ask you
questions about your memory of your relationship with your parents before
the age of 16. The questionnaires take about 10 minutes to be completed.
ACCESS TO MEDICAL FILE
We also ask your permission to access your clinical chart at the PEPP
Program, Douglas Mental Health University Institute. We will do this to
assess how well you are doing, the treatment you are receiving and the
symptoms that you may be experiencing. All information will be treated as
confidential (see confidentiality section below).
95
RISKS AND BENEFITS
Although there is no direct benefit for participating in this study, we assure
you that the information that you provide will help us improve services for
people experiencing a first episode of psychosis.
CONFIDENTIAL NATURE OF THIS STUDY
This project is confidential, which means that only individuals associated
with the study will have access to your information, unless otherwise
specified by law, and all information will be coded and kept in a drawer of
a locked filing cabinet at PEPP-Montreal of the Douglas Mental Health
University Institute under the supervision of Dr. Ashok Malla.
All data will be destroyed 10 years after the study has been completed. No
personal information will be released to third parties without your written
approval unless required by law. By signing this consent form, you are not
giving up any of your rights.
WITHDRAWAL FROM THE STUDY
Your participation in this study is voluntary, and your decision to
participate in this project, or to withdraw from the study at any time, will
have no consequences on the clinical services that you or your family
members may receive now or in the future.
COMPENSATION FOR PARTICIPATION IN THE STUDY
We will compensate you for parking and transportation for the extra visits
you will make for assessments related to participation in this study.
WHO CAN I TALK TO IF I HAVE ANY QUESTIONS ABOUT THIS
STUDY?
You can always contact any of the investigators at 761-6131 (extension
3418 for Dr. Ashok Malla, extension 2405 for Nadia Vracotas). If you have
any questions regarding your rights, you can contact the Douglas Mental
Health University lnstitute Ombudsman at 761-6131 extension 3287.
96
SIGNATURE
I have read and understood this consent form. I have been given sufficient
time and opportunity to ask questions. This study has been explained to
my satisfaction and all of my questions related to the study protocol have
been answered. I have been informed about the possible benefits and
risks related to my participation in the study and my questions have been
answered to my satisfaction. I understand that participation in this study is
voluntary and that I may withdraw from the study at any time and if I
withdraw, it will not affect the future care and attention which I will receive
from my doctors and my treatment team.
 By
signing and dating this consent form, I freely and voluntarily
agree to participate in this study. I will receive a copy of this signed
and dated informed consent form.
 I grant permission to place a copy of my consent form in my
hospital file. A copy of the informed consent form can be placed in
your Douglas Hospital medical file to facilitate communication
between clinicians during your visits to the hospital.
 I allow members of the research team of this study to consult my
medical file. Members of this research team may consult my
medical file to get information about my symptoms and my
treatment relevant to my participation in this study.
NAME _____________________________________________________
DATE OF BIRTH
_____/___/_____ (dd/mm/yyyy)
SIGNATURE________________________________________________
PARTICIPANT
DATE
CONTACT NO.
Note: If participant is under the age of 18, consent must be signed by both
the child and a parent or legal guardian.
97
I confirm that I have explained the nature of the study as well as any
potential risks and benefits to the participant whose name and signature
appears above.
NAME ______________________________________________________
SIGNATURE_______________________________________________
RESEARCH ASSISTANT
DATE
CONTACT NO.
SIGNATURE – PARENT/LEGAL GUARDIAN
I have read this informational and consent/assent form and have been
made aware of the study and its risks and procedures. Any questions I
had were answered to my satisfaction. I agree to my child’s participation in
this study. We do not waive our legal rights by signing this form.
SIGNATURE________________________________________________
PARENT OR LEGAL GUARDIAN
DATE
CONTACT NO.
SIGNATURE ________________________________________________
PERSON WHO OBTAINED
CONSENT
DATE
CONTACT NO.
SIGNATURE ________________________________________________
INVESTIGATOR
DATE
CONTACT NO.
98