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Editorials

Self esteem and health

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7415.574 (Published 11 September 2003) Cite this as: BMJ 2003;327:574

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Dr Marmot Was Too Environmental in His Self Esteem Editorial

Dr M Marmot presents a cascade of reasoning: "...Society is riddled
with inequality: of natural endowment...and of achievement. Hence these
inequalities will be accompanied by an inequality of respect. This, in
turn, will be accompanied by inequalities in self esteem". He mentions
"natural endowment" together with "achievement", but then goes on to
ignore natural endowment and to base his line of reasoning solely on
achievement.

For Marmot, achievement is what we all respect, and inequalitites of
respect for achievement lead on to, are accompanied, by inequalities in
self esteem. What happened to the "natural endowment", which accompanied
the "achievement" in the first place?

Natural endowment has, in my opinion, a much greater importance for
self esteem than Marmot and the various contributors have acknowledged.

Marmot touches on self esteem as being naturally endowed when he says
that "Low self esteem may be part of a depressive illness rather than a
step on the way".

Doyal and Gough are quoted for their idea that there are two basic
human needs, namely health and autonomy. But then Marmot makes the
assertion that autonomy and self esteem are closely linked, and couples
self esteem with the earning of respect without any attempt at justifying
this.

If health and autonomy are so basic, as Doyal & Gough indicate,
why does Marmot not consider them in terms of natural endowment? Instead,
it is the impact of the environment, in the input of earned respect, which
he couples with self esteem. And it is this environmentally shaped self
esteem which he says is "closely linked with autonomy".

No doubt that income inequality and the unequal distribution of
resources are related to low self esteem in some people at certain times.
And this is environmentally caused. But since Richard Sennett has given
"natural endowment" as one of the inequalities with which society is
riddled, should not Marmot have been more sympathetic to the biological
basis of self esteem?

His initially impressive Oscar comparison of a longer life expectancy
for the winning actors compared to the losers has lost all its persuasive
shine following the letter by Lawlor D et al, where Oscar winning
screenwriters died EARLIER than those who did not win. So the formation
of self esteem from the environment of respect earned from others for what
you have achieved has not yet been supported by science and remains
unproven.

I believe that natural endowment is more important than the
environment in the production of good self esteem.

As I understand it, self esteem is a belief; it is a belief about
oneself, about one's inner estimation of one's value and worth.

Self esteem is an opinion about one's self, and human opinions can be
as much a misinterpretation of reality as they can be accurate. Self
esteem is a judgment, which rests on grounds insufficient for complete
determination.

Self esteem is, therefore, exposed to many influences of a biological
and biopsychological nature, and not just to the level of environment-
respect received.

Marmot's linking of achievement with respect from others and self
esteem is illogical when stated as virtually the only cause of self
esteem. It seems to me axiomatic that there are high achievers, receiving
much praise and respect, who have private gremlins within themselves.

Such things can be, for example, embarrassing regrets over past
misdemeanours or failures, which keep coming back to haunt them; perceived
defects which they and no one else know about; an excessive alcohol intake
in the privacy of the home because the anxiety of maintaining the
functioning, upon which all the respect from others depends, requires self
-medication with alcohol to obtain relaxation at the end of the day; and
the memory of emotionally charged parental disapproval in the past.

I have used the word "biopsychological" because there are past
experiences and present belief systems, which have been taken up by the
protein-based, long-term memory in such a way that they become part of the
neural machinery of brain function. Past memories of parental disapproval
and of embarrassing situations, decades previously, return to spook the
highly respected individual as if these had occurred yesterday.

But there are belief systems that also become biopsychological in
nature. Here I am referring to the belief, long held by some people, that
God has a favourable opinion of you and despite what the human environment
thinks of you, if God thinks well of me then who am I to think badly of
myself.

If a person thinks that God esteems them highly, then self esteem is
unlikely to contradict such an opinion. A self esteem, which is based
upon or much influenced by a belief in God's benevolence, is neither
environmental nor biological in causation. Hence biopsychological!

However, there are biological conditions which do affect self esteem,
and Marmot has whispered about depression. Professionally, I treat many
adults with a condition known as Attention Deficit Hyperactivity Disorder.
In addition to the main features oF ADHD, these sufferers always have low
self esteem despite their professional or employment successfulness.

The speed of improvement in self esteem within half an hour of taking
the smallest dose of a dopaminergic, such as Ritalin or Dexamphetamine,
can only be biologically caused. And considering that ADHD is a
genetically determined insufficiency of dopamine production in the
prefrontal cortex of the brain, it is logical to believe that a swallowed
molecule, when interacting with the deficient neurones, should produce a
rapid improvement within a short space of time.

Finally, I am not impressed with Marmot's link between autonomy and
self esteem. The woman in the Middle Ages, for example, who decided to
enter a nunnery, lost much autonomy. However, she lost much personal
freedom, within which she was exposed to ravaging armies, roaming bandits
and murderous criminals.

To lose autonomy by entering a nunnery was to gain personal freedom
from rape, injury, robbery and even murder. To live in such a chronically
anxious state of personal damage is not consistent with anything but low
self esteem. The rise in self esteem on entering the safety of the
community of other women engaged in mutually agreed activites, makes a
loss of autonomy well worthwhile.

Surely, this is the strongest explanation for the meteoric rise in
the monastic population as Pax Romana disintegrated from the fourth
century onwards.

A slave in the Roman Empire could have been in a similar position.
Loyal and good service to a master was more likely to receive more respect
from the environment, and hence a higher self esteem, than to survive
precariously as a freedman in the unpredictably cruel underworld outside
the master's house.

And so, I believe that Marmot should have paid more attention to
Richard Sennett's "natural endowment & talent" in the formation of
good self esteem than to autonomy and achievement and environmentally-
produced respect from others.

Competing interests:  
None declared

Competing interests: No competing interests

18 September 2003
Dr P V Finn Cosgrove
Consultant All-Age Psychiatrist
The Bristol Priority Clinic, BA2 5YD