Journal List > J Korean Acad Psychiatr Ment Health Nurs > v.26(2) > 1058112

Lee and Park: Impact of Internalized Stigma, Anger Expression Style, and Mental Health Service Satisfaction on Self-esteem in Inpatients with Schizophrenia



This study was performed to identify how internalized stigma, anger expression style, and mental health service satisfaction impact on the self-esteem of inpatients with schizophrenia.


For this descriptive correlational study, 191 inpatients with schizophrenia participated. They had been admitted to one of six mental hospitals in three areas of South Korea. Data were collected from August 1 to November 30, 2016 using self-report questionnaires and data were analyzed using t-test, one-way ANOVA, Pearson correlation coefficients, and stepwise multiple regression with IBM SPSS 22.0.


The significant predictors of self-esteem in inpatients with schizophrenia were internalized stigma, anger expression style, and mental health service satisfaction, explaining 36% of the variance in self-esteem. The most significant predictor of self-esteem in inpatients with schizophrenia was internalized stigma.


Study findings suggest that a significant reduction in the internalized stigma of inpatients with schizophrenia increases their self-esteem. It is also, necessary to improve adaptive anger expression style and mental health service satisfaction.


1. Stephen HS, Stephen WN, Cleveland GS. Schizoprenia: a review. American Family Physician. 2007; 75(12):1821–1829.
2. Lee HY. Psychiatric hospital isolation, obsession status. 2015 human rights situation survey research service report. Seoul: National Human Rights Commission;2015 November. Report No. HETA 11-1620000-000587-01.
3. Kim E, Woo JM, Kwon JS. Cost of relapse in patients with schizophrenia in Korea. The Korean Journal of Psychopharmacology. 2011; 22(1):29–33.
4. Lee KA, Song BK. The effects of Mandala group art therapy on Schizophrenes' self-esteem. Korean Society Art Therapy Association. 2010; 17(6):1431–1446.
5. Reasoner RW. Building self-esteem. Palo Alto California: consulting Psychologists Press. 1982; 363.
6. Choi MO. The study on the self-esteem, group consciousness and consciousness of right of people who are mentally III. Korean Journal of Social Welfare. 2004; 56(2):145–166.
7. Keum R, Kim SA. Perceived functional health patterns and recovery in people with schizophrenia spectrum disorders. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2012; 21(3):238–249.
8. Lee MH. Meta-analysis on the effect of group counseling program for enhancing self-esteem [master's thesis]. [Jeonju]: Jeonju University. 2010; 72.
9. Yang HR. Sociological theory of Dilthey and G. H. Mead: focused on symbolic interactionism of Mead. Korean Hermeneutics Research. 2011; 27:145–170.
10. Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwend Vn BP. A modified labeling approach to mental disorder. American Sociological Review. 1989; 54(3):400–423.
11. Seo MK, Kim JN. Effects of perceived stigma on life satisfaction and self-esteem of the mental illness. Korean Journal of Social Welfare. 2004; 56(4):179–194.
12. Kim SY. Effects of stigma on self-esteem among individuals with mental illness. Mental Health & Social Work. 2014; 42(3):91–120.
13. Beck AT. Depression clinical, experimental, and theoretical aspects. New York: Hoeber Medical Division;1967. p. 370.
14. Jeon IJ. The relation of self-control and self-esteem on the adolescent's anger level and anger expression mode [master's thesis]. [Seoul]: Seogang University. 2002; 47.
15. Lee CH, Lee MG. The effect of anger management program for offenders on anger and self-esteem. The Korean Journal of Social and Personality Psychology. 2007; 21(1):35–46.
16. Jung HS, Song JY, Jung GJ. Anger experience and expression in patients with schizophrenia. The Korean Neuropsychiatric Association. 2000; 39(6):1045–1053.
17. Choi YJ. A study on mediating effects of community integration on recovery of the person with psychiatric disabilities. Mental Health and Social Work. 2010; 34:252–288.
18. Park BS, Bae SW, Lim SO. A Meta-analysis on the variables related with quality of life among persons with severe mental illness. Mental Health and Social Work. 2013; 41(3):63–92.
19. Kim CK, Lee JY, Song YS, Kim GH, Kim KR, Kim JW, et al. Development of the service satisfaction scale for psychiatric inpatients. Journal of the Korean Neuropsychiatric Association. 2006; 45(3):238–251.
20. Jung JH, Kwon HJ, Lee SG. The effect of mental hospital in-patient's perceived service quality on satisfaction and customer loyalty. Korean Journal of Hospital Management. 2012:17 (1). 23–42.
21. Ritsher JB, Phelan JC. Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatric Research. 2004; 129(3):257–265.
22. Hwang TY, Lee WK, Han ES, Kwon EJ. A study on the reliability and validity of the Korean version of internalized stigma of mental illness scale (K-ISMI). Journal of the Korean Neuropsychiatric Association. 2006; 45(5):418–426.
23. Spielberger CD, Krasner SS, Solomon EP. The experience, expression and control of anger. New York: Springer Verlag;1988.
24. Chon KK, Hahn DW, Lee CH, Spielberger CD. Korean adaptation of the state-trait anger expression inventory: anger and blood pressure. Korean Journal of Health Psychology. 1997; 2(1):60–78.
25. Korea University of behavioral science research laboratory. Psychological scale's handbook I. Seoul: Hakjisa;2012. p. 174–176.
26. Yang SH, Jeon KS. The effects of stress management program on perceived stress, stress coping, and self esteem in schizophrenia. The Korean Journal of Stress Research. 2015; 23(4):205–214. https//
27. Wie H. The effect of Korean traditional plays on the emotions, interpersonal relations, and self-esteem of persons with schizophrenia. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2009; 18(1):1–10.
28. Kim MY, Jun SS. Factors affecting internalized stigma of patient with schizophrenia. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2012; 21(2):108–117.
29. Kim MY, Ha SJ, Jun SS. Factors related to suicidal ideation in patients with chronic schizophrenia, depressive disorder, or bipolar disorder. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2015; 24(4):217–225.
30. Karidi MV, Stefanis CN, Theleritis C, Tzedaki M, Rabavilas AD, Stefanis NC. Perceived social stigma, self-concept, and self-stigmatization of patient with schizophrenia. Comprehensive Psychiatry. 2010; 51(1):19–30.

Table 1.
Differences in the Self-esteem according to General Characteristics for Subjects (N=191)
Characteristics Categories n (%) M±SD t or F p
Gender Male 102 (53.4) 15.93±4.32 0.16 .351
Female 89 (46.6) 15.81±4.41    
Age (year) <30 15 (7.9) 25.73±5.03 3.07 .067
30~39 41 (21.5) 26.02±4.52    
40~49 78 (40.8) 25.79±6.15    
50~59 39 (20.4) 28.05±4.71    
≥60 18 (9.4) 29.94±5.26    
Marital status Unmarried 119 (62.3) 26.76±5.92 2.36 .055
Married 34 (17.8) 25.92±5.39    
Divorce 22 (11.5) 29.13±5.30    
Bereavement 6 (3.2) 29.16±4.57    
Others 10 (5.2) 28.70±4.73    
Education Elementary school 10 (5.2) 23.50±4.50 2.12 .080
Middle school 25 (13.2) 25.08±4.99    
High school 99 (51.8) 26.74±5.83    
≤College 57 (29.8) 28.28±5.65    
Types of admission Voluntary 76 (39.8) 26.43±5.59 0.09 .602
Involuntary 115 (60.2) 26.86±5.46    
Frequency of hospitalization (month) <3 65 (34.0) 26.28±5.50 0.13 .971
≤3~6 24 (12.6) 26.62±4.44    
≥6 102 (53.4) 26.87±5.65    
Table 2.
Degrees of Internalized Stigma, Anger Expression Style, Mental Health Service Satisfaction, and Self-esteem for Subjects (N=191)
Variables M±SD Range
Internalized stigma 67.19±10.10 47~99
Anger expression style    
 Anger-in 17.05±4.59 8~29
 Anger-out 15.82±4.63 8~30
 Anger-control 20.36±5.15 8~32
Mental health service satisfaction 102.46±21.34 49~149
Self-esteem 26.69±5.50 10~40
Table 3.
Correlations between Self-esteem and Major Variables (N=191)
Variables Self-esteem
r (p)
Internalized stigma −.48 (<.001)
Anger-in −.30 (<.001)
Anger-out −.18 (.013)
Anger-control .27 (<.001)
Mental health service satisfaction .27 (<.001)
Table 4.
Predictors of the Self-esteem of Subjects (N=191)
Predictors B SE β t p
Internalized stigma −0.66 0.10 −.42 6.62 <.001
Anger-in −0.21 0.06 −.22 3.17 .002
Anger-out −0.13 0.06 −.14 2.10 .037
Anger-control 0.25 0.05 .29 4.24 <.001
Mental health service satisfaction 0.16 0.04 .21 3.61 <.001

Adj. R2=.36, F=23.04, p<.001

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