Self-esteem moderates affective and psychotic responses to social stress in psychosis: A virtual reality study
Introduction
Self-esteem can be described as the degree to which one values, approves or likes oneself. It is an affective evaluation of one's own worth, value or importance (Robinson et al., 2013) and also an important determinant of psychological health (Silverstone and Salsali, 2003). Low self-esteem is closely connected to a wide range of psychopathology (Zeigler-Hill, 2011), including depression (Orth et al., 2009), generalized anxiety disorder (Henning et al., 2007), obsessive compulsive disorder (Doron et al., 2008), borderline personality disorder (Zeigler-Hill and Abraham, 2006), and psychotic disorder (Kesting and Lincoln, 2013).
To explain the etiology of the relation between low self-esteem and psychopathological symptoms, two models have been proposed: the vulnerability model and the scar model (Zeigler-Hill, 2011). The vulnerability model proposes that low self-esteem is a risk factor for/a cause of developing psychopathology. The scar model states that low self-esteem is a consequence, not a cause, of psychopathology. The models do not mutually exclude each other, since low self-esteem may be both a cause and a consequence of symptoms. A recent meta-analysis examined the relation between self-esteem, and anxiety and depression, and found more support for the vulnerability model than the scar model: moreover, longitudinal data from both clinical and non-clinical samples demonstrated a significantly stronger effect of self-esteem on depression than of depression on self-esteem (Sowislo and Orth, 2012). High self-esteem protects individuals from developing symptoms, while persons with low self-esteem seem to lack sufficient resources to protect themselves from psychopathology (Zeigler-Hill, 2011). Thus, self-esteem and psychopathology appear to be interrelated networks.
A low level of self-esteem is often seen in patients with a psychotic disorder and is associated with higher levels of specific symptoms, such as hallucinations and persecutory delusions (Smith et al., 2006; Romm, 2010; Blairy et al., 2004; Karatzias et al., 2007; Silverstone and Salsali, 2003). In persons with psychosis, researchers found a strong positive association between negative self-esteem and positive symptoms, i.e. a negative self-image is related to more positive symptoms (Barrowclough et al., 2003). Also, a negative relation was found between positive self-esteem and negative symptoms, i.e. a positive self-image is related to less negative symptoms. Thus, self-esteem may be both a risk factor and a protective factor.
Paranoia, a core positive symptom in psychosis, is related to self-esteem (Thewissen et al., 2008; Kesting et al., 2013; Bentall et al., 2009; Atherton et al., 2016). Individuals who show paranoid reactions experience fear in relation to other people and fear of being deliberately harmed by others (Freeman and Garety, 2000; Freeman et al., 2002). In patients with psychosis as well as in the general population, self-esteem was shown to predict the onset of paranoia in daily life, i.e. when self-esteem decreased, levels of momentary paranoia increased (Thewissen et al., 2008; Thewissen et al., 2011; Kesting et al., 2013).
In persons with a psychotic disorder, self-esteem can be strongly negatively influenced by social stress (Lysaker et al., 2008; Gumley et al., 2004). Patients with psychosis are often highly sensitive to stress, which expresses itself in high affective or paranoid reactivity to stress (Lardinois et al., 2011). Stress sensitization may be involved in this process (Howes et al., 2016; Reininghaus et al., 2016; Collip et al., 2008; Myin-Germeys and van Os, 2007; Lardinois et al., 2011). Stress sensitization may develop when individuals are repeatedly exposed to environmental risk factor(s) and develop progressively greater psychological and/or physiological response to stress over time (Collip et al., 2008).
To further investigate affective and psychotic reactions in social situations, exposure to a controlled environment with social stressors is needed. However, the ‘real’ social environment is difficult to measure, let alone control, because it is highly complex, is never precisely the same, and is strongly influenced by the individual's behavior. By using Virtual Reality (VR), an interactive and immersive 3-dimensional virtual environment can be designed, which changes in response to an individual's movements and actions (Veling et al., 2014a). This enables exposure to a controlled experimental social environment (Veling et al., 2014b; Valmaggia et al., 2016). Characteristics of the virtual environment, including behavior of virtual characters (avatars), can be adjusted, enabling researchers to expose all participants to the same complex social stressors. VR is a safe, feasible and realistic technique to use for patients with psychotic disorders (Rus-Calafell et al., 2018). There is evidence that virtual avatars can induce affective and psychotic reactions (Freeman et al., 2010; Veling et al., 2016; Fornells-Ambrojo and Slater, 2013). Furthermore, exposure to VR, combined with threat belief testing, reduced paranoia levels in patients with a severe mental illness (Freeman et al., 2016). Also, a recent VR study showed that inducing low self-confidence in healthy individuals led to greater levels of paranoia in a neutral virtual environment (Atherton et al., 2016).
Recently, we reported a positive association between psychosis liability and paranoid and affective reactions to social stressors in VR (Veling et al., 2016). Specifically, persons with high liability to develop psychosis, showed, compared to persons with low psychosis liability, higher levels of paranoia and peak subjective distress when the levels of environmental social stress increased. Also, they demonstrated a higher basic level of paranoid thoughts and peak subjective distress. What explains differences in psychotic and affective responses between groups and individuals remains unclear. We theorize, substantiated by above described research, that low self-esteem might be involved. Since self-esteem is a modifiable target of treatment, this finding might be clinically relevant. The present study, using the same dataset as the previous research, investigated the role of self-esteem in levels of psychotic and affective responses to VR social stressors.
We hypothesized that:
- 1)
Positive and negative self-esteem are associated with lower respectively higher momentary paranoia, peak subjective distress, and stress reactivity after exposure to VR social stressors. These effects are stronger when level of social stressors increases;
- 2)
Higher psychosis liability is associated with lower positive self-esteem and higher negative self-esteem. The effects of self-esteem on momentary paranoia, peak subjective distress, and stress reactivity in VR are stronger in the higher psychosis liability group than in the lower psychosis liability group.
Section snippets
Participants
Participants were aged 18–35 years and were required to have sufficient command of the Dutch language. Exclusion criteria were a history of epilepsy and an intelligence quotient ≤ 75.
Two groups were compiled based on the level of psychosis liability. The group with higher psychosis liability consisted of individuals who were diagnosed with psychotic disorder ≤ 5 years ago. All DSM-IV categories of psychotic disorders were included, with the exception of substance-induced psychotic disorder and
Demographic data
Ninety-four participants with lower psychosis liability (53 controls, 41 siblings) and seventy-five with higher liability (20 UHR, 55 psychosis) were included. Level of education was significantly lower in the higher liability group, no differences were found in age, gender and ethnicity between the two groups. Demographic data are presented in Table 1.
Self-esteem, paranoia, peak subjective distress, and stress reactivity
The main effect of positive self-esteem on momentary paranoia, peak subjective distress, and stress reactivity was not significant (Table 3).
Discussion
This Virtual Reality study investigated the role of self-esteem in social stress responses. We found that negative self-esteem was associated with more paranoia and subjective distress in response to social stressors. These effects were stronger when level of environmental social stress increased, and were independent of psychosis liability. The impact of negative self-esteem on stress reactivity was stronger in persons with lower psychosis liability than in those with higher liability.
Financial support
This work was supported by the Netherlands Organization for Health Research and Development (Veni 916.12.013 to W.V.).
Conflict of interest
None.
Contributors
Authors RPK, MvdG and WV designed the study. RPK wrote the protocols. AJ, RPK and JC carried out research appointments. Authors AJ and WV carried out statistical analysis and AJ wrote the first draft of this manuscript. All authors contributed to and have approved this manuscript.
Acknowledgements
None.
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