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SELF-ESTEEM AS A PREDICTOR OF SUICIDE RISK AMONG PSYCHIATRIC PATIENTS

Muhammad Rizwan1 and Riaz Ahmad

Institute of Clinical PsychologyUniversity Of Karachi

ABSTRACT

Assessment of the predictive relationship of self-esteem with suicidal tendencies in

patients with psychiatric disorders is a core objective of the present study. After detailed

literature review, it was hypothesized that (1) Self-esteem would predict suicidal

tendencies among patients with psychiatric disorders. The sample of present study was

diagnosed psychiatric patients (N=140) according to Diagnostic and Statistical Manual

of Mental Disorders (DSM IV-TR; American Psychiatric Association, 2000) criterion and

were further divided in four sub-groups, including Patients of (a) Schizophrenia (N=40);

(b) Major Depressive Disorder (N=40); (c) Obsessive Compulsive Disorder (N=40); and

(d) Opioid Dependence Disorder (N=20). The age range of participants’ was18-25 years

(with the mean age of 22.14 years) and they belonged to middle socioeconomic status.

Research measures employed were: standard Intake form of Institute of Clinical

Psychology, University of Karachi, Rosenberg Self-Esteem Scale (Rosenberg ,1965), and

Suicidal Probability Scale (Cull & Gill, 1982). Descriptive statistics and linear

1 Muhammad Rizwan is a Clinical Psychologist at Institute of Clinical Psychology University of Karachi, Pakistan. He is PhD fellow at the same institute. He is involved in teaching along with research and clinical supervision of Interns at Institute of Clinical Psychology. His research work has mainly focused on clinical population’s self-esteem, suicidal risk potentials and social support as well as psychometric and cross-cultural studies. He may be reached at; [email protected]

mailto:[email protected]

regression analysis were employed to analyze the data in statistical terminology.

According to results self-esteem was found to be a statistically significant predictor of

suicidal tendencies in psychiatric group (R² = .608, F (1, 138) = 214.467, p <.05). These

findings have implications for clinical interventions.

INTRODUCTION

Suicide behaviors arise as daily life reactions to emotional chaos or

disappointment and mostly reflect the misery that exists in a society or cultural system

(Tseng, 2001). Worldwide, there are approximately 900,000 reported suicides each year,

including as many as 200,000 adolescents and young adults (Greydanus & Calles, 2007).

In psychiatric text it was reported that among various factors, low self-esteem is found to

be one of the stronger predictor of suicide behavior especially in psychiatric patients

(Beautrais, 2002; Crompton & Walmsley, 2002; Sadock & Sadock, 2007; Troister, Links,

& Cutcliffe, 2008).

The association of low self-esteem with suicide behavior in major depressive

disorder is widely studied and is well illustrated in literature. During depressive episode

the association between low self-esteem and suicidality was found (Daskalopoulou,

Dikeos, & Papadimitriou, et al. 2002; Tarrier, 2008). Likewise, Dori and Overholser

(1999) compared depressed adolescents who had never attempted suicide to depressed

adolescents who had attempted suicide to determine the level of hopelessness, self-

esteem, and depression across them. Results showed suicidal adolescents experienced

significantly lower self-esteem as well as higher levels of depression and hopelessness

than did non-suicidal adolescents. Self-esteem was found to be a better indicator of

suicide than a person’s level of suicidal ideation. Depressed and hopeless adolescents

with adequate level of self-esteem were less likely to demonstrate suicidal behaviors than

those with low self-esteem. Similarly, Overholser, Adams, Lehnert, and Brinkman (1995)

found that low self-esteem was related to higher levels of depression, hopelessness,

suicidal ideation, and an increased likelihood of having previously attempted suicide.

However this link is poorly studied in anxiety disorders and there are little

evidences in support and those to our knowledge are added here. Goodwin and Marusic

(2003) determined the association between feelings of inferiority and suicidal ideation

and suicide attempt among youth. They have found that feelings of inferiority were

associated with a significant increased likelihood of suicidal ideation and suicidal

attempt. The results also showed evidence of interaction specifically between anxiety

disorders and inferiority in the likelihood of suicidal ideation and between major

depression and inferiority in the likelihood of suicide attempt.

The high incidence of suicidal behavior in schizophrenia is also well documented.

Also, there is substantial amount of research which demonstrates the association of self-

esteem with suicidal behavior in schizophrenia. For example, Fialko, Freeman,

Bebbington, et al. (2006) studied the clinically significant trend of suicidal ideation in

psychosis and found that suicidal ideation was related with depressed mood, anxiety, low

self-esteem, negative illness perception, negative evaluative beliefs about the self and

others, and daily alcohol consumption. Likewise, Tarrier, Barrowclough, Andrews, and

Gregg (2004) found in their study that negative self-esteem was significantly correlated

with measures of depression, hopelessness and suicidal ideation, whereas positive self-

esteem was negatively correlated only with hopelessness in schizophrenia patients. They

concluded that isolation and poor self-worth/negative self-evaluation work through a

common factor of hopelessness to increase suicide risk in schizophrenia patients.

Researches have also indicated low self-esteem to be one of the factors associated

with suicidal behavior in drug dependence disorders. A study conducted by Wilke (2004)

designated a significant link in the predicted direction, between self-esteem and

abstinence and no effect for gender. Conversely, it was also assessed that those who had

lower levels of self-esteem, regardless of abstinence or continued use, had practically

indistinguishable likelihood of suicidal ideation. Likewise, Demibas, Celik, Ilhan, and

Dogan (2003) evaluated correlations of self-esteem, depression, and state-trait anxiety

with suicide probability in alcohol dependence. It was found that self-esteem, depression,

and trait anxiety predict suicide probability. Other researchers have found that alcohol

dependence disorder carry itself a loss of self-esteem and negative self-image and

suicidal process found speed up by presence of hopelessness that is usually seen in both

depression and alcoholism (Arikan, Cepik-Kuruoglu, Eltutan, & Isık, 1999; Cornelius,

Salloum, Mezzich, et al., 1995; Dukes & Lorch, 1989; Malone, Haas, Sweeney, & Mann,

1994).

On the basis of above mentioned analysis of literature it was hypothesized that:

1. Self-Esteem would predict Suicidal Tendencies among Patients with

Psychiatric Disorders

METHOD

Sample

140 psychiatric patients are participated in this study as volunteer subjects. These

samples recruited from population of those who had been taking treatment for their

mental health problems from outpatient clinics of different Psychiatric and Psychological

settings with in urban areas of Karachi and were diagnosed according to diagnostic

criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR;

American Psychiatric Association, 2000), including patients of (a) Schizophrenia (N=40);

(b) Major Depressive Disorder (N=40); (c) Obsessive Compulsive Disorder (N=40); and

(d) Opioid Dependence Disorder (N=20). Participants of Opioid Dependence Disorder

group comprised of males only, because of the unavailability of the females with Opioid

dependence disorder in out patient clinical setups of Karachi city.

Measures

Semi Structured Interview Form

This qualitative measure is designed by the Institute of Clinical Psychology,

University of Karachi, based on the criteria of Diagnostic and Statistical Manual for

Mental Disorders as well as other details necessary to screen out the diagnosis. It

consisted of items focusing on an individual’s demographic information, presenting

problems, history of problem, medical history, family history, educational history, social

and occupational history, recreational activities, sexual history, mental state examination,

extrasensory perceptions, belief system, affective state, anxieties, gender identity

problems, psychosomatic complaints, addiction problems, family psychopathology,

personality traits, motivation, and behavior during interview. It is a qualitative measure

which usually takes 20- 30 minutes to be administered.

Rosenberg Self-Esteem Scale

The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) is a 10-items scale

that was originally designed to measure the global self-esteem. It has a 4-point Likert-

type response format and each of the ten items has four possible responses: Strongly

Agree, Agree, Disagree, and Strongly Disagree. The scores can range from 0 to 30, with

the higher scores indicating high level of self-esteem and lower score indicating low level

of self-esteem. In the presented study translated version (Urdu Translation) of the RSE

(Sardar, 1998) was used. For the present study Cronbach’s alpha obtained was .87 that

shows appropriate internal consistency.

The Suicidal Probability Scale

The Suicidal Probability Scale (SPS; Cull & Gill, 1982) is 36-items; self- report

screening measure designed to aid in the assessment of suicide risk in adolescents and

adults. The major function of the SPS is to provide a global index of suicide risk on the

basis of sum of scores on four clinical subscales: Hopelessness, Suicide Ideation,

Negative Self-Evaluation, and Hostility. Individuals are asked to rate the frequency of

their subjective experience and past behaviors using a 4-point Likert scale format ranging

from “None or a little of the time” to “Most or all of the time.” The responses are then

hand scored to evaluate both general and specific suicide risk along several key

dimensions. The SPS is a self report measure of suicide risk that can be used as a research

instrument to provide quantitative scores. For the present study Udru translation of SPS

was used and Cronbach’s alpha (a measure of internal consistency) obtained was .93 that

shows good internal consistency.

Research Procedure

The sample was recruited from different psychiatric departments and mental

health clinics with in urban areas of Karachi. A letter of consent describing the research

project was provided to authorities of selected organization. After getting permission

from authorities, the psychiatric patients were approached individually with the help of

respective Psychiatrists and Psychologist who have already made a diagnosis of these

psychiatric patients. The first few minutes were spent putting the patients at ease and then

the purpose of the study was briefed and discussed in very general terms. The researcher

assured the confidentiality of the participant’s personal information and responses. The

formal consent was taken from patients through Consent Form and only those patients

who gave consent to participate were included in the sample. First, the researcher

conducted a detailed diagnostic interview and recorded all necessary information about

participant’s illness on Semi Structured Interview Form which further confirmed the

diagnosis made by the respective psychiatrist/psychologists according to the diagnostic

criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA,

2000). The participants’ final diagnosis was determined by a consensus meeting between

the researcher, respective psychiatrist/psychologist and an expert clinician’s opinion.

Finally, Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) and The Suicidal

Probability Scale (SPS; Cull & Gill, 1982) were administered to assess the psychiatric

patients’ level of self-esteem and suicidal risk potential. Participants were allowed to ask

questions if they had any difficulty in following instructions and understanding the

statements. At the end of the administration of research measures psychiatric patients and

concerned authorities were thanked for their cooperation and time. During the process of

study, researcher adhered to four key ethical principles: respect for the person’s rights

and dignity, responsibility, and integrity.

Statistical Analysis

After scoring, the research data was analyzed to interpret it in statistical

terminology. Data was initially compiled into a Microsoft Excel spreadsheet and then

analyzed on Statistical Package for Social Sciences (SPSS, V-13.0) software. Descriptive

statistics and linear regression analysis were employed to analyze the data in statistical

terminology.

RESULTS

Table 1Summary of Linear Regression with Self-Esteem as predictor of Suicidal tendencies (Hopelessness, Suicidal Ideation, Negative Self-Evaluation and Hostility) in Psychiatric Patients

Dependant Variable R R² Adj R²

Suicidal Probability Scale (total) .780 .608 .606

Hopelessness (Subscale) .727 .528 .525Suicidal Ideation (Subscale) .702 .492 .489Negative Self-Evaluation (Subscale) .572 .330 .325Hostility (Subscale) .699 .489 .485

df= 1, 138

Table 2Analysis of Variance for Linear Regression with Self-Esteem as predictor of Suicidal tendencies (Hopelessness, Suicidal Ideation, Negative Self-Evaluation and Hostility) in Psychiatric Patients

Model SS Df MS F Sig.

Suicidal Probability Scale

Regression 58424.300 1 58424.300 214.467 .000Residual 37593.493 138 272.417Total 96017.793 139

Subscales of Suicidal Probability Scale

Hopelessness


Suicidal Ideation


Negative Self-Evaluation


HostilityRegression 2777.150 1 2777.150 131.805 .000Residual 2907.672 138 21.070Total 5684.821 139

DISCUSSION

Suicidal risk potential is a product of psychiatric disorders but there are other

potential factors discussed by various researchers that elevate suicide risk in clinical

population and self-esteem is one of them (e.g., Wilke, 2004; Laukkanen, Korhonen,

Peiponen, Nuutinen, & Viinamaki, 2001; McGee & Williams, 2000). Our findings add on

these previous studies based on the following evidences. Statistical analysis indicates that

self-esteem explains 60% variation in the scores of suicidal tendencies for psychiatric

patients (R² = .608, F = 214.467, p <.05; Table 1 & 2). Additional regression analyses

have also been done for subscales of Suicidal Probability Scale (i.e., Hopelessness,

Suicidal ideation, Negative Self-Evaluation, and Hostility). Some interesting findings

have been found: Self-esteem explains 52% variation in the scores of hopelessness (R²

= .528, F(1, 138) = 154.447, p <.05; Table 1 & 2); 49% variation in the scores of suicidal

ideation (R² = .492, F = 133.890, p <.05; Table 1 & 2); 33% variation in the scores of

negative self-evaluation (R² = .330, F = 68.025, p <.05; Table 1 & 2); and 48% variation

in the scores of hostility (R² = .489, F = 131.805, p <.05; Table 1 & 2).

Self-esteem is a powerful resource for combating the effects of stress and suicidal

behavior among psychiatric patients. As Wolfe (2005) described that self-esteem implies

a tolerance for painful feelings that develops over time, as well as a willingness to

confront fears, take responsibility for feelings, decisions, and actions, and push on despite

obstacles and adversity. Whereas, Tarrier (2008) implied that feelings of low self-worth

can both inhibit the effective us of coping strategies and increase the risk of self-harm.

Thus, low self-esteem can increase psychiatric patients’ level of stress by reducing their

coping and effective problem solving. Consequently, they find life’s difficulties too hard

to cope with and develop feelings of hopelessness which in turn increases the likelihood

of suicidal behavior in psychiatric patients. Thus, one’s perception and the value assigned

to oneself play a very important role in suicidal behavior. High self-esteem can alleviate

one’s stress, enhance one’s stress tolerance and strengthens effective coping mechanisms

which in turn reduce suicidal tendencies in psychiatric patients.

Self-esteem has profound consequences for our existence (Branden, 1994).

Baumeister, Campbell, Krueger, and Vohs (2003) explained that it is difficult, if not

impossible, for people to remain indifferent to information that bears on their self-esteem,

such as being told that they are incompetent, attractive, untrustworthy, or lovable. Groves

and Muskin (2005) illustrated that for many people, feelings of accomplishment,

productivity, and usefulness are important for their self-image. Thus, self-esteem is

damaged when they lose this important source of gratification. They start personalizing

negative information about the self and perceive them as worthless and unproductive.

Consequently, increases and decreases in self-esteem generally bring strong emotional

reactions as Hayes, Strosahl, and Wilson (1999) described that as persons who commit

suicide evaluate them-selves quite negatively, believing themselves to be worthless,

inadequate, rejected, or blameworthy; the dominant motivation for suicide appears to be

an attempt to flee from aversive states of mind such as guilt, anxiety, worthlessness,

inadequacy, or blame. On the basis of our findings it can be concluded that among

psychiatric disorders the self-esteem is strong predictor. The findings suggest potential

pathways for developing effective prevention and intervention strategies for psychiatric

patients to improve level of self-esteem and reduce likelihood of suicide. The findings of

this study offer important suggestions to mental health professionals, health agencies,

community caretakers, and NGOs, etc.

This research focused only on the self-esteem as a predictor of suicidal behavior.

Future research considering the other variables, like, stigmatization, nature of stressors,

styles of coping, hopelessness, loneliness, personal, situational, and demographic

characteristics will also be fruitful in knowing the vulnerability to suicidal behavior

among psychiatric patients. Future researches should utilize samples of varied age groups

and of patients from different diagnostic categories. Also, future research should focus on

gender and socioeconomic status effects while working on the same variables.

There are several limitations of this study. One of the limitations of the study is

the limited power of generalizeabilty of the findings due the reasons, such as: Sample

with restricted age range i.e., young adults—also referred to as youth population— with

an age range of 18-25 years is selected. The sample comprised patients of only four

psychiatric disorders (e.g. Major depression, schizophrenia, obsessive compulsive

disorder and opioid dependence disorder). The prediction of suicide by self-esteem was

only a statistical estimation of the causal relationships, and it is not one that can be

obtained in a robust study design. Therefore, one should be careful while interpreting the

results. Last limitation of this study was the use of self-report measures to assess self-

esteem and suicidal risk.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (4th ed-TR). Washington, DC: Task Force.

Arıkan, Z., Cepik-Kuruoglu, A., Eltutan, H. & Isık, E. (1999). Alkol bagımlılıgı ve

depresyon. In H. Demibas, S. Celik., I. Ilhan, & Y. Dogan (2003), An

examination of suicide probability in alcoholic in-patients. Alcohol & Alcoholism,

38(1), 67-70.

Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high self-

esteem cause better performance, interpersonal success, happiness, or healthier

lifestyles? Psychological Science in the Public Interest, 4(1), 1-44.

Beautrais, A. L. (2002). Risk factors for serious suicide attempts among young people: a

case control study. In R. J. Kosky, H. S. Eshkevari, R. D. Goldney, & R. Hassan

(Eds.), Suicide prevention: The global context (pp.167-181). NY: Kluwer

Academic Publishers.

Branden, N. (1994). The six pillars of self-esteem. New York: Bantam.

Cornelius, J. R., Salloum, I. M., Mezzich, J., Cornelius, M. D., Fabrega, H., Ehler, J. G.,

et al. (1995) Disproportionate suicidality in patients with comorbid major

depression and alcoholism. American journal of psychiatry, 152, 358-364.

Crompton, N., & Walmsley, P. (2002). Community mental health services. In D. Duffy.,

& T. Ryan. (Eds.). New approaches to preventing suicide: A manual for

practitioners. London: Jessica Kingsley Publishers.

Cull, J., & Gill, W. (1982). Suicide probability scale (SPS) manual. Los Angeles,

California: Western Psychological Services.

Daskalopoulou, E. G., Dikeos, D. G., Papadimitriou, G. N., Souery, D., Blairy, S.,

Massat, I., et al. (2002). Self-esteem, social adjustment and suicidality in affective

disorders. European psychiatry, 17(5), 265-271.

Demibas, H., Celik., S., Ilhan, I., & Dogan, Y. (2003). An examination of suicide

probability in alcoholic in-patients. Alcohol & Alcoholism, 38(1), 67-70.

Dori, G. A., & Overholser, J. (1999). Depression, hopelessness, and self-esteem:

Accounting for suicidality in adolescent psychiatric inpatients. Suicide and life

threatening behavior, 29(4), 309-318.

Dukes, R. L., & Lorch, B. D. (1989). The effects of school, family, self-concept, and

deviant behavior on adolescent suicide ideation. In H. Demibas, S. Celik, I. Ilhan

& Y. Dogan (2003). An examination of suicide probability in alcoholic in-

patients. Alcohol & alcoholism, 38(1), 67-70.

Fialko, L., Freeman, D., Bebbington, P. E., Kuipers, E., Garety, P. A., Dunn, G., et al.

(2006). Understanding suicidal ideation in psychosis: Findings from the

psychological prevention of relapse in psychosis (PRP) trial. Acta Psychiatrica

Scandinavica, 114(3), 177-186.

Goodwin, R. D., & Marusic, A. (2003). Feelings of inferiority and suicide ideation and

suicide attempt among youth. Croatian medical journal, 44(5), 553-557.

Greydanus, D. E., & Calles, J. L. (2007). Suicide in children and adolescents. Primary

Care: Clinics in office practice, 34, 259-274.

Groves, M. S., & Muskin, P, R. (2005). Psychological response to illness. In J. L.

Levenson (Ed.), The American psychiatric publishing textbook of psychosomatic

medicine (p.70). NY: American Psychiatric Publishing, Inc.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment

therapy: An experiential approach to behavior change. NY: The Guilford Press.

Hidaka, Y., Operario, D., Takenaka, M., Omori, S., Ichikawa, S., & Shirasaka, T. (2008).

Attempted suicide and associated risk factors among youth in urban Japan. Social

psychiatry and psychiatric epidemiology, 43(9), 752-757.

Laukkanen, E., Honkalampi, K., Hintikka, J., Hintikka, U., & Lehtonen, J. (2005).

Suicidal ideation among help-seeking adolescents: Association with a negative

self-Image. Archives of suicide research, 9(1), 45-55.

Laukkanen, E., Korhonen, V., Peiponen, S., Nuutinen, M., & Viinamaki, H. (2001).A

pessimistic attitude towards the future and low psychosocial functioning predict

psychiatric diagnosis among treatment-seeking adolescents. Australian and New

Zealand journal of psychiatry, 35(2), 160-165.

Malone, K. M., Haas, G. L., Sweeney, J. A., & Mann, J. J. (1994). Suicide attempt

histories in alcohol-dependent men: differences in psychological profiles. The

International journal of the addictions, 29(11), 1477-86.

McGee, R., & Williams, S. (2000). Does low self-esteem predict health compromising

behaviors among adolescents? Journal of adolescence, 23(5), 569-582.

Overholser, J. C., Adams, D. M., Lehnert, K. L., & Brinkman, D. C. (1995). Self-esteem

deficits and suicidal tendencies among adolescents. Journal of the American

Academy of Child & Adolescent Psychiatry, 34(7), 919-928.

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton

University Press.

Sadock, B. J., Sadock, V. A. (2007). Kaplan & Sadock's Synopsis of Psychiatry:

Behavioral Sciences/Clinical Psychiatry (10th ed). Philadelphia: Lippincott

Williams & Wilkins.

Sardar, S. (1998). Study of relationships among childhood paternal loss, sex-role

orientation, self-esteem and locus of control in male and female students.

Unpublished PhD Dissertation. University of Karachi-Karachi, Pakistan.

Tarrier, N. (2008). Schizophrenia and other psychotic disorders. In D. H. Barlow (Ed).

Clinical handbook of psychological disorders: A step by step manual (4th ed., pp.

463-491). New York: The Guilford Press.

Tarrier, N., Barrowclough, C., Andrews, B., & Gregg, L. (2004). Risk of non-fatal

suicide ideation and behavior in recent onset schizophrenia: The influence of

clinical, social, self-esteem and demographic factors. Social psychiatry and

psychiatric epidemiology , 39(11), 927-937.

Troister, T., Links, P., & Cutcliffe, J.R. (2008). Review of predictors of suicide within 1

year of discharge from a psychiatric hospital. Current psychiatry reports, 10(1),

60-65.

Tseng, W. S. (2001). Handbook of cultural psychiatry. San Diego: Academic press.

Wilke, D. J. (2004). Predicting suicide ideation for substance users: The role of self-

esteem, abstinence, and attendance at 12-Step meetings. Addition research and

theory, 12(3), 231-240.

Wolfe, B. E. (2005).Understanding and treating anxiety disorders: An integrative

approach to healing the wounded self. Washington, DC: American Psychological

Association.

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