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Journal of Abnormal Psychology

2003, Vol. 112, No. 1, 9299

Copyright 2003 by the American Psychological Association, Inc.

0021-843X/03/$12.00 DOI: 10.1037/0021-843X.112.1.92

Self-Esteem in Schizophrenia: Relationships Between Self-Evaluation,

Family Attitudes, and Symptomatology
Christine Barrowclough, Nicholas Tarrier,
Lloyd Humphreys, Jonathan Ward, and
Lynsey Gregg

Bernice Andrews
Royal Holloway, University of London

University of Manchester
Participants with schizophrenia (N 59) were assessed on self-evaluation, symptomatology, and positive
and negative affect (expressed emotion) from significant others. An interview-based measure of selfevaluation was used and two independent dimensions of self-esteem were derived: negative and positive
evaluation of self. As predicted, negative self-evaluation was strongly associated with positive symptoms,
a more critical attitude from family members was associated with greater negative self-evaluation, and
analyses supported a model whereby the impact of criticism on patients positive symptoms was
mediated by its association with negative self-evaluation. The interview-based method of self-esteem
assessment was found to be superior to the questionnaire because its predictive effects remained after
depressed mood was accounted for.

[P]sychotic beliefs may be more firmly held if they are consistent

with firmly held distorted beliefs about the self (p. 191). Others
have seen the individuals experience of psychosis and hospitalization as lowering self-esteem, thus making some individuals
vulnerable to developing postpsychotic depression (Birchwood &
Iqbal, 1998; Iqbal, Birchwood, Chadwick, & Trower, 2000).
We suggest that a further important influence on self-esteem
is the immediate interpersonal environment. Parental attitudes
(Coopersmith, 1967; Rosenberg, 1965) and parental rearing styles
(e.g., Andrews & Brewin, 1990; Brewin, Andrews, & Furnham,
1996; Brewin, Firth-Cozens, Furnham, & McManus, 1992) have
been demonstrated to shape the self-esteem or self-critical attitudes
of young people. In adult life, Brown, Bifulco, Veiel, and Andrews
(1990) have demonstrated a strong association between negative
self-evaluation and negative relationships with partners, children,
and close friends. Thus, it seems likely that relatives negative
reactions to the problems and behaviors associated with the onset
of psychosis might lower self-esteem.
Living with a critical (or high expressed emotion [EE]) relative
is associated with a poorer outcome (Butzlaff & Hooley, 1998),
although little is known of the mechanisms of interaction between
relatives negative affect and symptom exacerbation. The relationship between high EE and schizophrenic relapse is generally seen
as a result of a stressful environment increasing patient arousal,
resulting in positive symptom exacerbation (Tarrier & Turpin,
1992); there is considerable experimental support for this hypothesis (e.g., Tarrier, Barrowclough, Porceddu, & Watts, 1988). However, although positive symptoms may be exacerbated by nonspecific high arousal states, psychological models of symptom
development suggest that negative self-schemas influence positive
symptoms. The interpersonal environment may impact on patient
cognitions about the self as well as on arousal; one possibility is
that high-EE relatives with marked criticism have an adverse effect
on the recipients self-worth. Low self-esteem may then strengthen
or maintain delusional beliefs in ways suggested by researchers
outlined above (Bentall & Kaney, 1996; Bentall et al., 1994;
Garety et al., 2001).

Negative attitudes and beliefs about self-worth, or low selfesteem, have been shown to be associated with many mental health
problems (Silverstone, 1991). To date, much of the work on the
relationship of self-esteem to well-being has focused on depression, where it has been suggested that negative self-esteem increases peoples vulnerability to mood disorder (Beck, 1967). In
recent years, self-esteem has become an important focus of study
in the context of psychological models of psychosis. After briefly
reviewing theoretical and methodological issues, in this article we
report a study that examined the relationship between self-esteem
and symptomatology in schizophrenia patients and tested a mediational model whereby the impact of criticism on patients psychotic symptoms (hallucinations and delusions) was mediated by
its association with negative self-evaluation.
The role of self-esteem in psychotic symptom causation has
been most prominent in the work of Bentall and colleagues (e.g.,
Bentall & Kaney, 1996; Bentall, Kinderman, & Kaney, 1994;
Kinderman & Bentall, 1996), who have proposed that paranoid
delusions result from attempts to maintain self-esteem in individuals with underlying low self-worth. A different mechanism was
proposed by Garety, Kuipers, Fowler, Freeman, and Bebbington
(2001), who suggested that negative self-concepts may contribute
to the formation and maintenance of some (negative content)
delusions and hallucinations through their thematic consistency:

Christine Barrowclough, Nicholas Tarrier, Lloyd Humphreys, Jonathan

Ward, and, Lynsey Gregg, Academic Division of Clinical Psychology,
School of Psychiatry and Behavioural Sciences, University of Manchester,
Manchester, United Kingdom; Bernice Andrews, Royal Holloway, University of London, London, United Kingdom.
We gratefully acknowledge Lynne Chatterton, Emese Csipke, and Alice
Knight for their help with the project.
Correspondence concerning this article should be addressed to Christine
Barrowclough, Academic Division of Clinical Psychology, School of Psychiatry and Behavioural Sciences, Second Floor Education and Research
Centre, Wythenshawe Hospital, Manchester M23 9LT, United Kingdom.
E-mail: christine.barrowclough@man.ac.uk


There are major methodological problems in studies of selfesteem and schizophrenia to date, which need to be addressed if
this area of research is to be developed. These problems are
illustrated by the lack of consensus about levels of self-esteem in
schizophrenia. Although several studies have suggested that selfesteem of patients with schizophrenia is no different to that of
normal controls (e.g., Kinderman, 1994; Krstev, Jackson, &
Maude, 1999; Lyon, Kaney, & Bentall, 1994), other studies have
found schizophrenia patients to have low self-esteem (Bowins &
Shugar, 1998; Freeman et al., 1998; Lecomte, Cyr, Lesage, Wilde,
& Leclerc, 1999; Silverstone, 1991). A number of factors may
account for these discrepant findings, including the different selfreport questionnaires used. The validity of using questionnaires in
measuring self-esteem has received criticism (Andrews & Brown,
1993; Brown, Andrews, et al., 1990) because they only assess
global self-esteem, the individuals positive or negative attitude
toward the self as a totality (Rosenberg, Schooler, Schoenbach, &
Rosenberg, 1995, p. 141). However, the multifaceted nature of the
self-concept has been emphasized (Markus & Wurf, 1987). First,
important distinctions have been made between peoples specific
and global self-esteem and, second, between the positive and
negative components of self-esteem (Andrews, 1998; Brown, Andrews, Bifulco, & Veiel, 1990).
Specific self-esteem refers to ones attitude to specific facets of
the selffor example, ones abilities as a parent or in an occupational or social role. Its relationship to global self-esteem depends
on how these specific facets rank in ones personal hierarchy of
self-values (Rosenberg et al., 1995). As regards positive and negative self-esteem, there is good evidence that these are independent
components reflecting different dimensions of the self-concept
(Andrews & Brown, 1993; Kohn & Schooler, 1969), termed selfconfidence (Rosenberg et al., 1995) and self-deprecation (Rosenberg et al., 1995) or self-derogation (Kaplan & Pokorny, 1969).
Thus, individuals may hold both strong positive and strong negative views about the self at the same time, with the two dimensions
not only making independent contributions to global self-esteem
but also making separate contributions to behavior and affect. By
focusing only on global self-esteem, questionnaire assessment
methods may thus generate unreliable and inconsistent results in
terms of predicting outcomes.
A further problem is that questionnaire measures of global
self-esteem are highly mood dependent (Andrews & Brown, 1993;
Rosenberg et al., 1995), which is not surprising given that global
low self-worth is itself a symptom of depression. Indeed, Rosenberg and colleagues have found that the negative correlation between the two variables seems to be due somewhat more to the
effect of depression on self-esteem than to the effect of self-esteem
on depression (Rosenberg et al., 1995, p. 145). This is an important issue for schizophrenia research because depression in psychosis is common, with prevalence estimates ranging from 22% to
75%, depending on criteria used (Birchwood & Iqbal, 1998).
In contrast with the psychometrically determined measurement
of global self-esteem derived from questionnaires, Brown et al.
(Brown, Andrews, Harris, Adler, & Bridge, 1986) developed a
complex, interview-based measure of self-esteem, the Self Evaluation and Social Support Interview (SESS; Andrews & Brown,
1991). Separate ratings of psychometrically valid negative and
positive self-evaluations were derived and the SESS measures
were found to be predictive of depression in women. This prediction was shown to be independent of mood and current sympto-


motology, in contrast to the Rosenberg Self-Esteem Scale (RSE;

Rosenberg, 1965), which failed to predict depression once current
mood state was controlled (Andrews & Brown, 1993). Andrews
and Brown (1993) suggested that the SESS measure reflects more
enduring cognitive vulnerability because it taps both specific and
salient areas of self-dissatisfaction in real-life situations and is
therefore less mood dependent than the global questionnaire
In view of the potential importance of the self-concept in schizophrenia and the problems of measurement identified in previous
studies, our study used a version of the SESS modified for use with
schizophrenia patients. This assessment permitted the measurement of both positive and negative dimensions of self-esteem.
Psychological models of schizophrenia symptoms have focused on
the possible contribution of negative self-evaluation to delusions
and hallucinations formation and maintenance but have not considered the role of positive self-regard. Positive evaluation of self
has been found to have considerable benefits for mental health,
including predicting recovery from depressive episodes (Brown,
Bifulco, & Andrews, 1990). There is also some evidence that
parental approval is associated with higher self-esteem (Brewin et
al., 1996). We suggest that the relationship between positive regard
from significant others and positive self-evaluation merits further
investigation in schizophrenia.
The purpose of the present study was to test the interrelationships between positive and negative self-evaluation, symptomatology, and positive and negative affect from significant others in
people with a schizophrenia diagnosis. In a cross-sectional study,
we first tested the associations between the self-esteem measures
and symptomatology. We predicted that negative self-evaluation
would be associated with greater overall symptomatology (both
positive and negative symptoms of schizophrenia) but that we
would see the strongest relationship with positive symptoms (hallucinations and delusions). We were guided by the theory (e.g.,
Garrety et al., 2001) that negative self-concept was causally implicated in positive symptom development and maintenance. Although we also predicted an association between negative symptoms and negative self-evaluation, we expected this to be due to
the common effects of depression on both negative symptoms
(e.g., as suggested by Norman, Malla, Cortese, & Diaz, 1998) and
self-evaluation (as emphasized by Rosenberg et al., 1995). We also
explored the relationship between positive evaluation and symptomatology without a priori hypotheses.
Second, we examined the associations between self-esteem dimensions and negative and positive affects from a key relative,
derived from EE ratings. We predicted that the greater the criticism, the more marked would be the negative self-evaluation,
whereas positive relatives affect would be associated with greater
positive self-evaluation. We further investigated whether patients
perceptions of relatives negative evaluations of them mediated the
impact of criticism from a significant other on ones negative
evaluation of self.
Third, we examined the combined and independent contributions of relatives criticism and negative self-evaluation to patient
symptomatology. We predicted that negative evaluation of self
would operate as a mediator between criticism and symptomatology. In a mediational model of criticism and low self-esteem,
greater symptoms would be supported if self-esteem explained a
significant proportion of the hypothesized criticismsymptoms
linkage (Baron & Kenny, 1986).


Participants and Procedure

Patients were included in the study if they fulfilled the following criteria:
clinical diagnosis of schizophrenia, schizophreniform, or schizoaffective
disorder in accordance with criteria of the Diagnostic and Statistical
Manual of Mental Disorders (4th edition; DSMIV; American Psychiatric
Association, 1994), confirmed by two research assistants (Lloyd
Humphries and Lynsey Gregg) conducting a systematic chart review using
a checklist of DSMIV criteria; a history of illness of less than 3 years (so
as to minimize the potential confounds of illness length on self-esteem);
English speaking; between the ages of 18 to 65; if recruited as an inpatient,
then their psychotic symptoms had been stabilized for at least 6 weeks;
contact with a relative or significant other of at least 10 hr face-to-face
contact per week; and informed consent to participate in the study. For
patients with more than one relative, the person with the major carer role
was selected. Patients were interviewed on two occasions. Session 1
consisted of symptom assessment and was carried out by a research
assistant blind to the self-esteem assessment. Session 2 included the
modified Self Evaluation and Social Support Interview (SESS-sv; Humphreys, Barrowclough, & Andrews, 2001) and the RSE. The relatives
assessments were conducted within 2 weeks of the patients interviews.

The modified SESS-sv interview and scales. The SESS-sv is a semistructured interview (Humphreys, Barrowclough, & Andrews, 2001) modified from the Andrews and Brown (1991) SESS. The SESS-sv takes
approximately 45 min to administer and consists of six sections. The first
five sections focus on different life domains: social and recreational,
occupational, relationships, parenting, and homemaking. Questions in
these sections involve both perceived competence and commitment in each
possible role; responses are used in an overall rating of Evaluation of Role
Performance. A further SESS-sv section concerns self and has questions
covering Evaluation of Personal Attributes (traits and characteristics such
as physical attractiveness, intelligence, and the ability to get along with
people) and more general self-acceptance (the individuals more generalized feelings about him- or herself, such as the degree to which they are
happy with themselves and any specific feelings regarding their desire to
be different). All ratings take into account the importance and salience of
the roles and attributes to the individual.
Interviewers made ratings from audiotapes and were assisted by guidelines for rating each component, for anchor points, and for rating examples.1 Five scales are used to assess self-evaluation, using the following
4-point rating system: 4 marked, 3 moderate, 2 some, and 1
little/none. Scores on these five scales are summed to obtain the two
dimensions of self-esteem. The Negative Evaluation of Self dimension
(NES) consists of the three scales of Self Acceptance, Negative Evaluation
of Personal Attributes, and Negative Evaluation of Role Performance; the
score range is from 12 (high NES) to 3 (low NES). The Positive Evaluation
of Self dimension (PES) consists of the two scales of Positive Evaluation
of Personal Attributes and Positive Evaluation of Role Performance; the
score range is from 8 (high PES) to 2 (low PES).
The independence of the PES and NES indices was confirmed using a
principal-components factor analysis and using varimax rotation on the
five scales (Humphreys et al., 2001). Two factor patterns emerged that
showed both a positive and a negative scale. The Negative scale consisted
of negative evaluation of personal attributes, negative role performance,
and self-acceptance. Positive evaluation of personal attributes and positive
role performance loaded on the Positive scale. The NES scale has acceptable internal reliability (Cronbachs .76). An alpha coefficient was not
computed for the Positive scale because it consists of only two items that
showed a correlation of .18, demonstrating the independence of the two
scales. Interrater reliability for the SESS-sv, calculated for 12 consecutive
interviews, was determined by two independent raters using weighted

Cohens kappa coefficients for each of the five scales. The coefficients
showed good agreement, ranging from .62 to .89. Interrater reliabilities for
the two self-esteem scales (PES and NES) were also calculated on the
same 12 interviews, using intraclass correlations: NES scale .92, PES
scale .89. The stability of the scales was tested on a random selection
of 13 patients who completed the assessments at two time points approximately 3 months apart. Neither the NES nor the PES change scores
differed significantly from zero: PES, t(12) 0.89; NES, t(12) 1.33,
indicating that the scales testretest scores were within the 95% limit of
agreement. Correlations between the scores at the two time points were .87
for the NES and .45 for the PES. Although the testretest correlation for the
PES is low, this reflects changes in patient score rankings rather than a
significant change in scores over time: 5/13 (38%) of patients retained the
same score, and for 10/13 (77%) the difference was, at most, one point on
the scale.
Questionnaire measure of self-esteem. The RSE (Rosenberg, 1965)
was included to permit comparison with other studies. A high total score is
indicative of low self-esteem (range 10 40). The independence of
positive and negative self-esteem in the Rosenberg SE was tested by factor
analysis using varimax-rotated, principal-components factor analysis.
When we entered the individual items into a factor analysis equation, three
factors emerged. The first factor consisted of the five positive items, and
the second factor loaded on four of the negative items. The third factor
consisted of one single negative item: All in all, I am inclined to feel I am
a failure. In the light of the factor analysis, subsequent analyses used the 2
scale scorespositive and negativeas well as the total (global selfesteem) score.
Negative evaluation from the key relative. Following the format of the
original SESS, one section of the SESS-sv questioned the patient about the
key relatives negative evaluation of them. A 4-point scale (from 4
marked negative evaluation of subject to 1 little/none) was then used to
assess the extent and degree to which the patient reported that the key
relative made negative comments about their performance, personality, and
other personal attributes. Only reported comments of relatives were used as
rateable material. Interrater agreement for the scale was based on two raters
independently scoring the scale for eight cases. There was complete agreement for seven cases, and for the single discrepancy one rater felt there was
insufficient material to score.
Patient symptomatology. Psychotic symptomatology was measured by
interview, using the Positive and Negative Syndrome Scale (PANSS; Kay,
Fiszbein, & Opler, 1987), which measures 32 symptoms on 7-point Likert
scales, deriving three composite subscales: Positive, Negative, or General
Psychopathology. Intraclass correlation coefficients (ICCs) were calculated
between the assessor (Lloyd Humphreys) and the average rating of three
gold-standard raters2 on 14 videotaped PANSS interviews. ICCs were as
follows: Positive scale .97, Negative scale .79, General Psychopathology scale .88.
Depression and mood. The PANSS Depression scale (G7) was used to
assess depression (score range 17); the Beck Depression Inventory
(BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) was used as a
self-report measure of mood (score range 0 63).
Relatives EE. EE was measured from audiotaped Camberwell Family
Interviews (CFI). The CFI (Vaughn & Leff, 1976) was conducted with the
patients key relative. The EE scales of relevance in this study are those
reflecting negative affect, Criticism and Hostility, and those associated
with positive affect, Warmth and Positive Remarks. A trained rater
(Jonathan Ward) administered the interview and rated the EE scales from
the audiotape. Interrater reliability was 100% on overall EE status, and

The interview, rating criteria, and psychometric data are contained in a

manual that is available from Christine Barrowclough.
The gold-standard raters were three research psychiatrists from the
School of Psychiatry and Behavioural Sciences, University of Manchester,
Manchester, United Kindgom.

correlations of scale scores were as follows: .99 for critical comments, .80
for hostility, .98 for EOI, .97 for warmth, and 1.00 for positive remarks.

The sample consisted of 69 diagnosed patients. Of these, 10
patients (14.5%) withdrew their consent during assessment. This
resulted in a total sample size of 59 with the following diagnoses:
schizophrenia (n 49, 83%), schizophreniform disorder (n 7,
12%), and schizoaffective disorder (n 3, 5%). The age range was
from 18 to 48 years (M 27.2, SD 7.6), 45 (76%) were male,
and the majority (88%) were not married. Twenty percent of
participants (12) lived alone, whereas more than half (34, or 58%)
lived with their parents, 6 (10%) with partners, and 7 (12%) with
friends or in other shared accommodation. Thirty-six (61%) had an
illness duration of less than 1 year, 17 (29%) had a duration of 12
years, and 6 (10%) had a duration of 23 years. Twenty-three
(39%) were inpatients at the time of recruitment.
Interview-based and questionnaire self-report self-esteem scores
are presented in Table 1. Self-esteem in the present sample (mean
total RSE score 23.7) was lower than that of psychosis patients
in Krstev et al.s (1999) study3 (M 16) but comparable to that of
Silverstones (1990) psychosis sample. On a 10-point scoring
system, the mean RSE score in the psychosis population of Silverstone was 4.0 (SEM 0.62) compared with the current sample
mean of 4.02 (SEM 0.31) and with a mean score of 2.9 in a
normal control group of comparable age (McLennan, 1987).
Scores from the SESS-sv indicated that participants as a group
had moderately high negative self-evaluation4 (mean NES
score 7.9, SD 2.1, possible range 312) and moderately

Table 1
Means and Standard Deviations for Symptom, Self-Esteem, and
Expressed Emotion Scores


PANSS Positive
PANSS Negative
PANSS Depression
PANSS Suspiciousness/Persecutory Ideas
PANSS Delusions
PANSS Auditory Hallucinations
PANSS Total score
BDI score
Negative evaluation of role performance
Negative evaluation of personal attributes
NES total score
Positive evaluation of role performance
Positive evaluation of personal attributes
PES total score
Rosenberg Positive scale
Rosenberg Negative scale
Rosenberg total score
Critical comments
Positive comments



Note. PANSS Positive and Negative Syndrome Scale; BDI Beck

Depression Inventory; NES negative evaluation of self; PES positive
evaluation of self.


good positive self-evaluation (mean PES score 5.3, SD 1.0,

possible range 2 8). Using categories from Brown, Andrews, et
al. (1990), we found 24 people had high negative self-evaluation
(NES score 9 12), 33 had moderate self-evaluation (NES
score 5 8), and 2 had low self-evaluation (NES score 3 4).
The mean scores for the PANSS, mood assessment, and EE are
presented in Table 1. Of the 59 patients, a total of 40 (68%) had a
key relative who was rated as high EE on the basis of emotional
overinvolvement, criticism, or hostility. Thirty-three relatives
(56% of total sample) were rated as high EE on the basis of making
six or more critical comments and/or having a high rating of
hostility (high-EE marked criticism).

Self-Esteem and Symptomatology

In Table 2, we examine relationships between scores from the
PANSS and the self-esteem measures. Examining first the overall
NES, in line with our predictions, the greater the total symptomatology, the higher the NES score. The association with negative
symptoms alone was weaker, nonsignificant, and reduced when
depression was controlled. Again in line with our predictions, the
greatest association with NES was found for severity of positive
symptoms. The relative associations between NES and positive
symptoms and NES and negative symptoms were compared using
procedures suggested by Meng, Rosenthal, and Rubin (1992).
Results showed that the correlation between NES and positive
symptoms is significantly greater than the correlation between
NES and negative symptoms (z 1.99, p .05). This relationship
of NES and positive symptoms remains, even when controlling for
depression (which was found to be strongly associated with selfesteem measures). Inspecting the three scales that contribute to
NES, negative evaluation of personal attributes clearly makes the
strongest contribution to the relationship, which remains robust
when depression is controlled. The relationship is strong for both
delusions and hallucinations, even when the contribution of depression is partialed out. A different picture is seen for the overall
positive evaluation of self (PES), where negative associations with
positive symptoms are weak and nonsignificant. Unlike NES, for
PES there is an association with negative symptoms that is independent of depression. However, in the absence of a priori hypotheses about positive esteem and symptoms, multiple correlations
increase the possibility of chance significance. Using the Bonferroni method to correct for this, we found that none of the PES
associations with symptoms reached significance. We examined
associations between the questionnaire measure of self-esteem
(RSE) and symptomatology. There was some association with the
PANSS total score, but this association fell well below significance level once depression was controlled. Given that there were
no further associations with the PANSS subscales, it seems reasonable to conclude that any association between the RSE and
The scoring in the study by Krstev et al. (1999) was the reverse to that
used in the current study (that is, higher scores indicated higher selfesteem; H. Krstev, personal communication, 2001); hence, the score has
been reversed here for comparison purposes.
Comparing the NES score with that of samples in Andrews and
Browns (1993) study, the mean was comparable to that of those women
meeting criteria for major depressive disorder (M 8.16, SD 1.5) and
higher than the nondepressed group (M 5.68, SD 1.48).



Table 2
Bivariate Correlations Between Self-Esteem Measures and Symptomatology (With Partial Correlations, Controlling for Depression)
NES scale

controlling for


Total PANSS score .52***

Positive symptoms
Negative symptoms .23


of role

of personal




Self-Esteem Inventory

PES scale


of role

of personal








.26* .34***
0.01 0.00
.13 .04
.21 .18

Note. NES negative evaluation of self; PES Positive evaluation of self; PANSS Positive and Negative Syndrome Scale; BDI Beck Depression
* p .05. ** p .02. *** p .01.

symptomatology is due to its measurement of negative affect

reflected in the RSE.
The above correlations examining associations between selfesteem and symptoms were repeated, controlling for current mood
(BDI scores). A pattern of results similar to that when controlling
for observer-rated depression was evident (see Table 2).

Associations Between Relatives EE and

Patients Self-Esteem
Table 3 presents correlations between the relevant EE dimensions of interest5 and the self-esteem measures. In line with our
predictions, the greater the number of relatives criticisms, the
higher the overall negative evaluation (NES score). The association was strongest for the negative evaluation of personal attributes
but was also evident for negative role performance. There was also
some association between hostility and poorer PES, which was
strongest for role performance. Examination of positive affects
indicated that there were no significant associations between overall PES and the Warmth and Positive Comments scales. However,
the greater the relatives warmth, the higher the positive evaluation
of role performance.
When the sample was split into two groups according to
high-EE marked criticism and low-EE criticism and compared on
the self-esteem measures, a significant difference was found with
regard to negative evaluation of personal attributes, t(57) 2.04,
p .05.
Comparing the groups according to hostility (high-EE hostility
vs. high-EE marked criticism alone and low EE), a significant
difference was found with regard to total PES score, t(57) 2.05,
p .05, and patients with hostile relatives had lower positive
evaluation of self. They also had greater negative evaluation of
role performance, t(57) 2.15, p .04.

Symptomatology and EE
The PANSS Positive Symptoms scale showed a modest correlation with number of critical comments. More association was
evident between negative symptoms and critical comments and
hostility (see Table 4).

Relationships Among Symptomatology, Self-Evaluation,

and Family Affect
The correlational data confirmed the following predictions: (a)
associations between NES and positive symptom severity, (b) NES
and a critical family attitude, and (c) symptom severity and relatives criticism. Having established this pattern of interrelationships, we conducted a series of linear regression analyses to test
the proposed model whereby low self-esteem mediated the relationship between criticism and symptoms: negative family affect
(criticism)negative self-evaluation greater positive symptoms.
Following Baron and Kennys (1986) approach, the model would
be supported if, when positive symptoms were regressed on NES
and criticism, the association between criticism and symptoms was
reduced whereas the association between NES and symptoms
remained significant. The results of this series of analyses provided
support for this model. The relationship of criticism to positive
symptoms was reduced, and family attitude was no longer a
significant predictor of positive symptoms with NES in the model
(from 0.26, t[57] 2.03, p .05, to 0.15, t[56] 1.2),
whereas NES remained strongly related to symptoms ( 0.32,
t[56] 2.4, p .02).
Given that we hypothesized a relationship between criticism and selfesteem only, the emotional overinvolvement measure was not included in
the analyses.



Table 3
Bivariate Correlations Between Relatives Expressed Emotion and Patients Self-Esteem
NES scale

PES scale


of role

of personal


Positive comments





of role

of personal




Note. NES negative evaluation of self; PES positive evaluation of self.

* p .05. **p .02. ***p .01.

In a second set of analyses, we investigated the possibility that

the relationship between family attitude and NES was mediated by
the impact of the criticism on the patient (negative evaluation from
a key relative, measured by the SESS). Due to the strict criteria
noted above for rating this material from interviews, reports of
negative evaluation from a relative were not available for some
participants; thus, sample size was restricted to 41 for these analyses. Regression analyses gave support to this proposal. Actual
critical comments by a key relative (EE rating) were significantly
related to patients reports of relatives negative evaluation
( 0.35, t[39] 2.36, p .03) and to NES ( 0.33, t[57]
2.6, p .02). The relationship of relatives criticism (EE rating)
to NES was reduced and was no longer a significant predictor of
self-evaluation when perceived negative evaluation was in the
model ( 0.24, t[38] 1.6), whereas patients report of relatives negative evaluation remained strongly related to NES
( 0.38, t[38] 2.5, p .02).

The results of the study endorse the superiority of an interviewbased measure over questionnaire methods of assessing selfesteem in schizophrenia and highlight the need for researchers to
control for current mood state when investigating self-esteem in
psychosis clients. Two independent dimensions of self-esteem
were derived from the interviewNES and PESand as predicted, NES was strongly associated with positive symptoms.
Again in line with our predictions, a more critical attitude from a
family member was associated with greater NES. Furthermore,
Table 4
Correlations Between Expressed Emotion Dimensions
and Symptomatology
PANSS scale


Total score




Note. PANSS Positive and Negative Symptom Scale.

* p .05. ** p .02. *** p .01.


statistical evidence supported a model whereby the impact of

criticism on positive symptoms was mediated by its association
with NES.
Our confirmed prediction of an association between positive
symptoms and NES was based on the theory that negative selfconcept is implicated in positive symptom development and maintenance. Although the data do not exclude the possibility that low
self-esteem is associated with a generally poorer symptom profile,
two factors suggest a specific relationship between negative selfconcept and positive symptoms. First, the association of low
self-esteem with psychopathology was not seen globally across
symptoms. The association with NES was weaker for negative
symptoms and seemed mainly due to shared mood variance, as we
had hypothesized. Second, it was the negative evaluation of the
Personal Attributes subscale that was most closely associated with
positive symptoms. This scale rates peoples descriptions of negative aspects of their personal qualities, traits, and perceived character deficits. Thus, the measure would seem to tap directly into
peoples underlying beliefs or negative schemas about the self.
Although causal inferences cannot be drawn because of the crosssectional nature of the data, we suggest that influences might be
bidirectional: negative schema contributing initially to delusional
formation, with experience of illness (including the critical reaction of significant others) increasing negative self-beliefs and
maintaining or reinforcing delusional ideas associated with a negative self (Im evil/being punished/being plagued by evil spirits,
The independence of the measures of PES and NES indicates
that it is possible for people with psychosis (as for others) to retain
strong positive beliefs about the self while having strong negative
beliefs about the self. In the absence of follow-up data, we are
unable to assess whether positive self-evaluations afford some
advantage in regard to future outcomes, as was demonstrated in
predicting recovery among chronically depressed women in
Brown, Bifulco, and Andrews study (1990).
Although low PES showed a small association with hallucinations, its main association was with negative symptoms. People
who had a higher positive evaluation had fewer negative symptoms. Because of the multiple correlation testing in the absence of
a priori hypotheses, this association should be viewed very cautiously, especially because there is little available research to guide
interpretation. Although an association between depression and
negative symptoms has been demonstrated and discussed in the



literature (e.g., Norman et al., 1998), little attention has been paid
to self-esteem and negative symptoms.
The prediction of an association between positive affect from
relatives and PES received only weak support. There were no
associations with the global PES, but the EE dimension of warmth
was associated with positive evaluation of role performance. This
finding lends support to Lopez, Nelson, Mintz, and Snyders
(1999) proposal that prosocial family processes have been largely
neglected in schizophrenia and merit further investigation. When
we looked at relatives negative affect, criticism was associated
with both positive and negative patient symptoms, although only
positive symptoms were mediated by NES. Previous research and
theory have indicated that negative symptoms tend to attract criticism from relatives (e.g., Hooley, Richters, Weintraub, & Neale,
1987; Weisman, Nuechterlein, Goldstein, & Snyder, 1998). From
this study, one might speculate that self-esteem is only a mediating
variable between negative comments and symptoms when the
criticisms are salient to an individuals self-evaluation. This model
is supported by evidence that patients reports of negative evaluation by relatives mediated the relationship between relatives
actual criticism and low self-esteem. Moreover, we argue that NES
is more likely to impact on positive symptoms directly (because of
the influence of personal schemas on delusional beliefs; Garrety et
al., 2001), whereas it has less of an impact on negative symptoms
(which are cognitive and behavioral deficits).
Again, as with all correlational analyses, direction of causality is
questionable. We also emphasize that we do not suggest that
critical relatives influence on symptomatology operates solely by
its impact on self-esteem. The nonspecific impact of a critical
interpersonal atmosphere on symptoms via arousal levels is an
important and well-supported theory in schizophrenia (Tarrier &
Turpin, 1992). The personal relevance of the criticism may be less
important than the strain of relationship difficulties and arguments
triggered by the relatives dissatisfactions. However, we do suggest that the influence of the social environment on self-esteem
may increase our understanding of the broad impact of EE across
a range of mental health problems (Wearden, Tarrier, Barrowclough, Zastony, & Rahill, 2000), given that many mental health
problems are associated with low self-esteem (Silverstone, 1991).
This potential mechanism for the interpersonal environment to
maintain or exacerbate symptoms through direct influence on NES
may be particularly pertinent in disorders in which self-esteem is
strongly implicated in psychopathology. For example, a relatively
low threshold of critical comments is associated with increased
relapse for depression (Hooley, Orley, & Teasdale, 1986), a disorder strongly associated with low self-esteem. The link found in
the study between NES and EE is also supported by the wellreplicated finding that relatives who are critical tend to attribute
the symptoms and problems of the schizophrenic illness to factors
controllable by the patient (Barrowclough, Tarrier, & Johnstone,
1994; Brewin, MacCarthy, Duda, & Vaughn, 1991; Lopez et al.,
1999; Weisman, Lopez, Karno, & Jenkins, 1993; Weisman et al.,
1998). These blaming attributions may well increase the patients self-blame, thereby decreasing self-worth.
The results from this study have considerable implications for
psychological interventions with psychosis patients. From the findings, we predict that interventions that target negative self-worth
may have a beneficial impact on positive symptoms. The links
between EE, self-esteem, and symptoms also have implications for
family-based treatments. Although studies have demonstrated the

benefits of family work in schizophrenia (see Mari & Streiner,

1996, and Penn & Mueser, 1996, for reviews), lack of understanding of the precise way in which EE might exacerbate symptoms
has necessarily meant that clinicians are uncertain about the optimum methods for family interventions and the best targets for
change as regards family behaviors (Barrowclough & Tarrier,
1998). Our findings emphasize the need for interventions with
psychosis clients that continue to take the social context into
account and for family work to pay particular attention to helping
relatives to develop less negative appraisals of patient behavior.
We have emphasized that this study has a number of limitations
that restrict the interpretation of its findings. Most important, the
cross-sectional design precludes causal inferences and does not
permit the testing of the predictive validity of the self-esteem
measures in terms of symptom outcomes. However, the consistency of the findings strongly suggests that there are important
relationships among self-evaluation, family attitudes, and symptomatology in schizophrenia that merit further investigation.

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Received December 24, 2001

Revision received June 15, 2002
Accepted July 7, 2002