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Comprehensive Psychiatry 58 (2015) 57 67
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Changes of explicitly and implicitly measured self-esteem in the treatment

of major depression: Evidence for implicit self-esteem compensation
Ingo Wegener a,, Franziska Geiser a , Susanne Alfter a , Jan Mierke b , Katrin Imbierowicz a ,
Alexandra Kleiman a , Anne Sarah Koch a , Rupert Conrad a
a
Department of Psychosomatics, University Hospital Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
b
(r)evolution GmbH, Heussallee 12, 53113 Bonn, Germany

Abstract

Background and objectives: Self-esteem has been claimed to be an important factor in the development and maintenance of depression.
Whereas explicit self-esteem is usually reduced in depressed individuals, studies on implicitly measured self-esteem in depression exhibit a
more heterogeneous pattern of results, and the role of implicit self-esteem in depression is still ambiguous. Previous research on implicit self-
esteem compensation (ISEC) revealed that implicit self-esteem can mirror processes of self-esteem compensation under conditions that
threaten self-esteem. We assume that depressed individuals experience a permanent threat to their selves resulting in enduring processes of
ISEC. We hypothesize that ISEC as measured by implicit self-esteem will decrease when individuals recover from depression.
Methods: 45 patients with major depression received an integrative in-patient treatment in the Psychosomatic University Hospital Bonn,
Germany. Depression was measured by the depression score of the Hospital Anxiety and Depression Scale (HADS-D). Self-esteem was
assessed explicitly using the Rosenberg Self-Esteem Scale (RSES) and implicitly by the Implicit Association Test (IAT) and the Name Letter
Test (NLT).
Results: As expected for a successful treatment of depression, depression scores declined during the eight weeks of treatment and explicit
self-esteem rose. In line with our hypothesis, both measures of implicit self-esteem decreased, indicating reduced processes of ISEC.
Limitations: It still remains unclear, under which conditions there is an overlap of measures of implicit and explicit self-esteem.
Conclusions: The results lend support to the concept of ISEC and demonstrate the relevance of implicit self-esteem and self-esteem
compensation for the understanding of depression.
2014 Elsevier Inc. All rights reserved.

1. Introduction criticized for at least two reasons: First, participants have to

Major depressive disorder is known to be the most
prevalent mental disorder. About 5% of the population suffer
from depression [1], while approximately one fifth develop
one or more episodes of major depression in their life [2].
Self-esteem has been claimed to be an important factor in
the development and maintenance of depression [3]. Studies
show self-esteem scores to be reduced in depressed
individuals [4,5]. The majority of these studies employ
self-report questionnaires to measure self-esteem. However,
although widely used, self-report data have longtime been
Corresponding author. Tel.: +49 228 287 16299; fax: +49 228 287
15382.
E-mail address: i.wegener@gmx.de (I. Wegener).
http://dx.doi.org/10.1016/j.comppsych.2014.12.001
0010-440X/ 2014 Elsevier Inc. All rights reserved.
be motivated to disclose their genuine attitudes, e.g.,
individuals may give biased answers due to reasons of
social desirability. Second, they must also be able to access
the construct that they are asked about, e.g., some may
misattribute emotions and thus cannot answer questions
aiming at the reasons of their emotions correctly. The
implicit measurement of an attitude aims at overcoming
these limitations by the following principles: (1) the
participant's awareness of the fact that this specific attitude
is measured may be reduced, (2) the participant may not have
conscious access to the attitude in focus, and (3) the
participant's control over the outcome of the measurement
may be limited [6]. Thus, implicit measures might be less
biased by deliberate attempts to conceal the attitude and that
they might even reflect attitudes of which the respondent is
not aware (p. 401) [7].
58 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
Although measures of implicit self-esteem were repeatedly
criticized to have only low to modest reliability and insufficient
convergent validity [8,9], several studies obtained results
indicating that implicit self-esteem comprises information that
goes beyond the information provided by explicit measures of
self-esteem [10,11]. Bosson et al. [8] concluded that among
measures of implicit self-esteem, reliability was best for the
Implicit Association Test (IAT) [12] and the Name-Letter Test
(NLT) [13,14]. Subsequently, the majority of empirical research
relies on these measures [9] (see method section for a detailed
description of both measures).
Dual process accounts to cognitive vulnerability to depres-
sion [15,16] suggest that two processing systems determine how
an event is interpreted. The automatic or implicit system
operates by automatically activating memory concepts in an
effortless and unintentional manner and without charging
cognitive resources. The deliberate or explicit system is
characterized by effortful, intentional resource consuming
processing. Haeffel et al. [16] assume that life events first
trigger a rapid, automatic, and unintentional response that may
activate negative self-schemas. In a second step this interpre-
tation may be reinterpreted by explicit processes. Whereas some
researchers presume that the main cause of cognitive vulnera-
bility lies within negative implicit self-schemas [17], other
investigators assume that explicit cognition can be the source of
vulnerability to depression [18].
Haeffel et al. [16] tested the predictions of dual process
models and observed in their first study, that only
participants with lower implicit self-worth (IAT) experi-
enced immediate emotional distress after a failure feedback.
In their second study, using a prospective design, they found
that implicit self-worth (IAT) as well as explicit cognitive
styles interacted with negative life events in predicting later
depression. When entered simultaneously into a regression
model, only explicit self-worth interacted significantly. The
authors argue that implicit self-worth affects immediate
distress, whereas explicit cognitions determine the long-term
risk to depression. Also supporting the role of explicit
processing, Steinberg et al. [19] found implicit self-esteem as
measured by IAT to predict depressiveness only for
individuals with depressogenic cognitive style.
Taking a closer look at implicit self-esteem in depressed
individuals reveals a mixed picture (see DeHart et al. [20] for
a more detailed review): De Raedt et al. [21] observed
implicit self esteem in currently depressed individuals to be
as high as in non-depressed controls using the IAT (study 1)
and the NLT (study 2). In study 3 they observed higher
implicit self-esteem for depressed compared to non-
depressed participants using the Extrinsic Affective Simon
Task (EAST, cf. De Houwer [22]). Accounting for suicidal
ideation in depressed individuals, Franck et al. [23] find
lower implicit self-esteem (IAT) in a depressed sample
without suicidal ideation than in a non-depressed group as
well as in depressed individuals with suicidal ideation.
Implicit self-esteem of depressed with suicidal ideation
was as high as in the non-depressed group. Unfortunately,
suicidal ideation was not controlled in other studies on
implicit self-esteem in depressed samples and as a
consequence we do not know to what extent the results are
affected by suicidal ideation. Gemar et al. [24] observed
higher implicit self esteem (IAT) in formerly depressed than
in never depressed and currently depressed participants, but
after negative mood was induced, implicit self-esteem of
the formerly depressed dropped to the level of the never
depressed and the currently depressed. This pattern of results
was replicated by Franck et al. [25]. However, Franck et al.
[26] observed no differences in implicit self-esteem using the
NLT in currently, formerly, and never depressed individuals.
Nevertheless, implicit self-esteem predicted future depres-
sive symptomatology. Risch et al. [27] accounted for the
number of depressive episodes and observed that implicit
self-esteem (IAT) was the same for never depressed and
remitted patients with recurrent depressive episodes, which
both had higher implicit self-esteem than first-onset
depressive patients and currently depressive patients with
recurrent depressive episodes.
Taken together, the most frequent finding is that currently
depressed and non-depressed samples do not differ with
respect to implicit self-esteem [21,25,26], although implicit
self-esteem has also been found to be reduced [27] or
elevated [21] in currently depressed individuals compared to
non-depressed. Furthermore, implicit self-esteem can be
moderated by suicidal ideation [23] and history of depression
in depressed [27] or remitted [27,24,25] patients, but see Franck
et al. [26] for contrary results. Moreover, implicit self-esteem in
remitted patients is affected by mood induction [24,25]. Despite
the stable finding of reduced explicit self-esteem in depressed
populations, reduced implicit self-esteem seems not reliably
associated with clinical depression in cross-sectional studies.
A possible explanation for these heterogeneous results may be
compensatory responses to self-threatening situations, as will be
outlined in the following paragraphs.
Based on research demonstrating that implicit self-esteem
improves after participants have been confronted with self-
threatening situations, several authors proposed that self-
defensive processes can be triggered under conditions of
threat to the self and that these processes can compensate
potential loss in self-esteem [10,28,29]. They argue that
measures of implicit self-esteem are particularly sensitive to
these compensatory processes. The studies that focused on the
consequences of self-threatening situations in healthy individ-
uals used different ways to manipulate self-threat. For example,
Jones et al. [29] observed enhanced implicit self-esteem after
participants with high explicit self-esteem wrote about an aspect
of themselves they wish to change but not when they were asked
to write about a positive aspect of themselves or a self-irrelevant
topic. Other studies yielded analogous effects on the liking
of others with similar names [30] or choosing brands with
names resembling their own name [31] after participants had
performed a self-threatening writing task. Improved implicit
self-esteem was also observed after negative life events [28] and
social rejection [10].
 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
Rudman et al. [10] propose an automatic self-esteem
defense mechanism called implicit self-esteem compensation
(ISEC) that automatically regulates self-esteem whenever the
self is seriously threatened. They argue that given the high
frequency of threats to the self in everyday life, the idea of a
process that buffers self-esteem would be compelling. They
propose that ISEC is an automatic self-regulatory mecha-
nism that countervails self-decrementing situations in an
effortless manner. This account may explain why implicit
self-esteem is not reduced in depressed samples as reviewed
above. Based on the findings that healthy individuals employ
this mechanism when confronted with ego-threats, it makes
sense to assume a similar mechanism in depressed
individuals: depressed individuals reveal low explicit self-
esteem [4,5], adverse self-schemas [3234] and overestimate
the frequency of future life events [35]. They are prone to
disadvantageous attribution styles [36] as they attribute
negative life events internally but positive life events
externally (see Sweeney et al. [37] for a meta-analytic
review of 104 studies) thereby experiencing more self-
threatening events [3840]. Given this daily struggle with
threatening events on the one hand, and the results of
elevated implicit self-esteem after manipulations of threats to
the self [10,29] on the other hand, we expect implicit
self-esteem compensation to be a most relevant process in
depression. ISEC may thus be a reason, why depressed
individuals reveal consistently reduced levels of explicit but
not implicit self-esteem as reviewed above. The heteroge-
neous results concerning the relative extent of implicit
self-esteem of depressed in comparison to healthy individ-
uals may be a consequence of ISEC protecting the depressed
self from adverse threats. Implicit self-esteem compensation
may often reach or sometimes even prevail the level of
healthy controls. Within the dual process framework ISEC
can be understood as a mechanism stabilizing implicit
self-esteem. In this conception implicit self-esteem may
fluctuate in response to self-threatening events and thus
exhibit a state component [28]. In dual process accounts for
the vulnerability to depression, implicit self-esteem is often
understood as rapid and automatic processing mode that
develops over a long period [15] and is based on stable
memory constructs [16]. However, there is evidence that
implicit self-esteem can be affected by classical conditioning
[41], induction of negative mood [24,25], daily negative
events [28], or after threats to the self [10,2831]. DeHart
and Pelham [28] argue that implicit self-esteem has trait as
well as state aspects and propose that implicit self-esteem has
a trait level around which the state level can fluctuate. If
depressed individuals possess a low level of implicit
self-esteem, ISEC may represent such a fluctuation that
can elevate implicit self-esteem to a level observed in
non-depressed controls. This may explain, for example, why
depressed individuals with suicidal ideation, but not without
suicidal ideation, revealed higher implicit self-esteem than
non-depressed [23]. Self-threat is presumably extremely
pronounced in individuals with suicidal ideation and, as a
59
consequence, ISEC may yield particularly high levels of
implicit self-esteem. Furthermore ISEC may also explain the
frequent finding that implicit self-esteem is generally
positive, even in samples with major depression. For
example the performance of currently depressed participants
in the IAT reveals stronger associations for self-positive and
other-negative than for self-negative and other-positive
combined trials [21,27]. Also the NLT is positive for
depressed individuals as they prefer letters from their own
name over other letters [21,26]. Given the more negative self-
schemas that are observed in depressed individuals, one may
expect negative scores for these measures of implicit self-esteem.
The frequently observed positive implicit self-esteem in
depressed samples may also be a consequence of ISEC, because
depressed individuals are in particular need of processes that
compensate the omnipresent threats to their self.
In the present study we examine the role of implicit
self-esteem compensation for depressed individuals by
focusing on the change of explicit and implicit self-esteem
during the course of treatment of inpatients with major
depression. Because many studies demonstrated that explicit
self-esteem improved as a consequence of the successful
therapy of depression [4,5] we accordingly expect to
replicate this pattern in the present study (hypothesis 1). If,
in contrast to explicit self-esteem, implicit self-esteem
compensation is protecting the self of depressed individuals
against daily threats as suggested above, one would suppose
a particularly high implicit self-esteem at the beginning of
treatment which, as protective processes decrease during
recovery, decreases as patients recover from depression. We
thus expect implicit self-esteem to decline during the course
of treatment (hypothesis 2).
2. Method
2.1. Participants
51 consecutive inpatients of the Psychosomatic Univer-
sity Hospital Bonn, Germany, diagnosed with major
depression participated in the present study. Main reason
for hospitalization was limited functioning in everyday life
that did not improve sufficiently during out-patient treat-
ment. All had been diagnosed by an experienced psycho-
therapist of the Psychosomatic University Hospital
Outpatient Unit in an approximately two hour diagnostic
and anamnestic interview using DSM-IV-TR [42] diagnostic
criteria. Included were participants aged from 20 to 65 years.
Exclusion criteria were a comorbid psychotic episode or
limited German language skills that were insufficient to fill
in the questionnaires. However, no participants had to be
excluded. Patients were asked to complete the Implicit
Association Test [12] on a computer and afterwards to fill in
several questionnaires for a first time during the first week
and for a second time during the last week of their inpatient
treatment (see below). During the treatment, six patients
dropped out. In two cases, patients left hospital a few days
60 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
before the date of planned discharge due to organizational
reasons. In one case the treatment was discontinued because
the patient with comorbid anorexia nervosa was not fulfilling
her weight gain contract for more than three weeks. One
patient discontinued the treatment because of difficulties in
emotion regulation when confronted with annoying behavior
of some other patient. One patient had somatic complications
and one patient discontinued her treatment when she realized
that a former coworker of her had been admitted to the
treatment program.
At the beginning of the treatment, there were no
differences between drop outs and completers with respect
to age (t(50) = 0.02, p = .98), gender ( 2 (1) = 0.27, p =
.61), depression measured by HADS-D score (t(49) = 1.77,
p = .08), explicit self-esteem (t(49) = 0.03, p = .98), or
implicit self-esteem (t(50) = 0.28, p = .78 for the IAT score
and t(48) = 1.60, p = .12 for the Name Letter Test). Among
the 45 participants who completed questionnaires at the
beginning and end of treatment there were 36 females (80%)
and 9 males (20%). Average age was 35.24 years (SD =
11.73), 27 (60%) had completed high school, seven (16%)
had a university degree. At the entry of the treatment 13
(29%) received no psychotropic medication, 23 (51%)
received antidepressants, 10 (22%) sedatives, and 4 (9%)
antipsychotics. Psychiatric comorbidities were personality
disorders (n = 20), eating disorders (n = 15), anxiety
disorders (n = 9), somatoform disorders (n = 4), and
posttraumatic stress disorder (n = 1).
2.2. Measures
2.2.1. Rosenberg Self-Esteem Scale (RSES)
Explicit self-esteem was measured using the German
translation by von Collani and Herzberg [43] of the
Rosenberg Self-Esteem Scale [44]. Von Collani and
Herzberg criticized the psychometric properties of one item
of an earlier German version of the RSES [45]. They
translated this item more closely to Rosenberg's English
version and obtained an improved corrected item-total-
correlation for this item. The German RSES comprises 10 items
that are 4-point Likert-scaled from 0 (does not apply at all) to
3 (applies completely). Von Collani and Herzberg observed
Cronbach's of .84 and .85 in two independent samples. In
the present study, we observed a Cronbach's of .87 at the
beginning as well as at the end of treatment.
2.2.2. Hospital Anxiety and Depression Scale (HADS)
Depressive and anxious symptomatology was assessed
using the German version [46] of the Hospital Anxiety and
Depression Scale [47]. Respondents are asked to indicate
how they have been feeling over the past week on a 4-point
Likert scale. The questionnaire consists of a 7-item subscale
measuring anxious and a 7-item subscale measuring
depressive symptoms. The latter scale was used in the
analyses reported in the present study. Based on a review of
747 studies using the HADS, it has been stated that the two
factor structure was supported by the data and that reliability,
sensitivity, and specificity were sufficient [48]. In the present
study Cronbach's of .79 for anxiety and .82 for depression
were observed at the beginning of the treatment, whereas the
Cronbach's were .81 and .86 for anxiety and depression,
respectively, at the end of the treatment.
2.2.3. Implicit Association Test (IAT)
The Implicit Association Test for self-esteem was
developed by Greenwald and Farnham [12] as an implicit
measure of self-esteem on the basis of the procedure of the
standard IAT [49]. In this computerized speed categorization
task, the participants' task is to assign words of the categories
self versus other and positive versus negative by pressing
one of two response keys. Usually participants perform
better in compatible trials, where self-related words (e.g.,
me, my) are mapped on the same key as positive words
(e.g., luck, pleasure) and other-related words (e.g., it,
the) on the same key as negative words (e.g., poison,
betrayal). If self-related words are assigned to the same key
as negative words and other-related words to the same key as
positive words, participants perform worse (incompatible
trials). It is assumed that the faster reaction times for
compatible than for incompatible trials reflect stronger
associations for the materials mapped on the same keys in
the compatible trials. If the self is associated with positive
rather than negative concepts, as one would expect in case of
positive self-esteem, participants should answer faster if they
are required to press the same key for me and pleasure
(compatible trial) than for me and betrayal (incompatible
trial). In order to reduce the influence of training effects,
Greenwald [49] suggested using different kinds of blocks
consisting of training trials. In the present study the trials
were presented in blocks of 48 trials each. It was balanced
between patients whether they had to work on compatible or
incompatible blocks first. The IAT procedure consisted of
672 trials grouped in five phases, including training blocks:
1. Two blocks with self- and other-related words only, 2.
Two blocks with positive and negative words only, 3. Four
mixed blocks (these blocks were all compatible or
incompatible, depending on balancing condition), 4. Two
blocks with self- and other-related words only, but with
switched key assignment, 5. Four mixed blocks using this
switched assignment. The dependent variable was calculated
from the two phases with mixed blocks (phases 3 and 5)
according to the algorithm suggested by Greenwald et al.
[50], whereas phases 1, 2, and 4 served as training blocks
only. Stimulus words were presented in black letters on a
light gray background in a rectangle of 20 mm 120 mm
on a 17 inch display. Response stimulus interval was set to
250 ms. The response keys were to be pressed by different
hands, and matching of stimulus categories to the dominant
versus non-dominant hand was counterbalanced across
patients. Responses were accepted as soon as a stimulus
was visible.
The IAT is the most frequently used measure of implicitly
measured self-esteem [9]. Although studies on the IAT were
 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
quite promising at the beginning [12,51], more recent
overviews compiled more mixed results [9,52].
2.2.4. Name-Letter Test (NLT)
The Name-Letter Test [13,14] is another frequently used
task that aims at assessing self-esteem implicitly. The idea
behind this measure is that a person's self-esteem affects the
extent of liking the letters of one's own name. Indeed it is a
stable finding that people like their initials more than other
letters [53]. Although it has been questioned if this
preference can serve as a measure of self-esteem [9,53],
there is evidence that NLT comprises information that goes
beyond explicit self-esteem [28,54,55]. In the present study
participants were asked to evaluate all letters of the alphabet
with regard to how much they like each letter of the alphabet
on a 9-point Likert scale. Letters were presented in
randomized order that was generated for every patient and
for each time of measurement anew. To avoid artifacts
because letters that are generally evaluated more favorable
may be more frequently found as name letters, the evaluation
of a participant's name letter is usually corrected by
calculating the difference of this evaluation and the average
evaluation of this letter by all other participants that do not
have this letter in their name. However, Albers et al. [56]
argued and demonstrated that this score is still confounded
with the general liking of letters of the participant. They
propose an alternative name-letter score that is calculated as
the average evaluation of someone's names letters minus the
weighted average evaluation of letters that are not part of the
person's name and the weighted average evaluation of the
same letters rated by participants not possessing these letters
in their names. Albers et al. [56] found significant
correlations of this score with the Rosenberg Self-Esteem
Scale and with internal but not external narcissism. In the
present study, we use this improved scoring algorithm of the
Name-Letter Test.
2.3. Treatment conditions
The mean duration of the inpatient treatment in the
present study was 55.69 days (SD = 10.76). Patients
participated four times a week in a 1.5 hours psychodynamic
group therapy. In addition they received one individual
psychodynamic therapy session and two 1.5 hours group
sessions of concentrative movement therapy every week.
Concentrative movement therapy aims at making biograph-
ical material topic by using experiences emerging from
movement work. It is based on psychodynamic and Gestalt
principles. Furthermore, patients joined a weekly cognitive-
behavioral role-play group and a weekly psychodynamic art
therapy session lasting 1.5 hours each. Finally, they
participated in progressive muscle relaxation groups twice
a week. Four patients with panic disorder and/or agoraphobia
and one patient with a specific phobia in addition joined a
manual based cognitive-behavioral therapy with ten indi-
vidual sessions including exposure therapy focusing panic
symptoms and avoidant behavior. The four patients with
61
anorexia nervosa additionally approved a weight gain
contract and had to maintain a food diary. Similar integrative
treatment conditions are common in German psychosomatic
hospitals and have repeatedly been shown to provide good
effectiveness [57,58]. Moreover, the specific treatment
conditions at the Psychosomatic University Hospital Bonn
were demonstrated to be effective [59,60].
2.4. Procedure
All patients participated during the first and the last week
of their in-patient treatment at the Psychosomatic University
Hospital, Bonn, Germany, on a voluntary basis. Patients
were first administered an Implicit Association Test for self
esteem [12] on a computer and afterwards they were asked to
fill in several questionnaires including Rosenberg Self-
Esteem Scale [43] and the Name-Letter-Test [13,14]. The
sessions took about two hours at beginning as well as at end
of treatment.
2.5. Statistical analysis
For the statistical analyses IBM SPSS version 20 for
Windows was used. Alpha error level was set to .05. Power
analyses with g*power [61,62] for the matched t-tests used
below with a sample size of 45 to test for medium effects
resulted in a power of (1 ) = .95. Because one patient did
not fill in the HADS properly at the end of treatment and one
other patient did not complete the ratings for the NLT at the
end of treatment, the sample size is accordingly diminished
for the statistical tests on these variables.
2.6. Ethical statement
All patients participated on a voluntary basis and signed
informed consent forms. Permission to conduct the study
was granted by the ethics committee of the University of
Bonn, Germany (Lfd.Nr. 175/09).
3. Results
Comparisons of explicitly and implicitly measured self-
esteem as well as depression at beginning and completion of
treatment are presented in Table 1. Differences were tested
by matched pairs t-tests revealing significantly increasing
explicit self-esteem, while implicit self-esteem and depres-
sion decrease during the course of treatment. Spearman's
Rho correlations between the two points of measurement
indicate comparably high stability of implicitly measured
self-esteem, implying some extent of reliability inherent in
these measures. Note that the means of IAT and NLT scores
are significantly larger than zero at both times of
measurement (all p's b .001), indicating a positive implicit
self-esteem. This means, e.g. for the Name Letter Test, that
patients evaluated the letters of their own name generally
more positive than did patients that did not have these letters
62 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767

Table 1
Means, standard deviations, matched pairs t-statistics, effect sizes, and correlations of depression, explicit, and implicit self-esteem.
Beginning of End of Comparisons of beginning vs. end
treatment treatment of treatment
Mean SD Mean SD T-value Cohen's d Spearman's Rho (t1-t2)
Explicitly measured depression
HADS-D 10.73 4.39 5.95 4.17 7.11 1.07 .42
Explicitly measured self-esteem
RSES 13.47 6.97 18.78 6.29 4.64 0.69 .30
Implicitly measured self-esteem
IAT 0.64 0.38 0.55 0.32 2.15 0.32 .62
NLT 2.84 0.98 1.95 0.93 6.04 0.91 .59
RSES = Rosenberg Self-Esteem Scale; IAT = Implicit Association Test; NLT = Name Letter Test; HADS-D = Hospital Anxiety and Depression Scale
depression score; t-tests were conducted with df = 43 for NLT and HADS-D and df = 44 for all other variables.
p b .05.
p b .01.
p b .001.

in their names, but this positive evaluation decreased across
the course of treatment.
The Spearman's Rho correlations of the three measures of
self-esteem are presented in Table 2 for both points of
measurement separately. Neither the correlations of the two
implicitly measured self-esteem scores nor the correlations
of implicitly and explicitly measured self-esteem are
statistically significant. However, correlations of explicit
self-esteem and depression scores reveal a strong negative
relationship mirroring that the more depressed individuals
reported lower explicit self-esteem, whereas no significant
correlations were observed for depression scores and
implicitly measured self-esteem.
4. Discussion
Current psychological theory defines self-esteem as a
person's overall appraisal of his or her own worth. The
self-concept is what we think about the self; self-esteem, the
positive or negative evaluation of the self, is how we feel about
it (p. 107) [63]. Since psychological theory distinguishes
between automatic and unconscious self-evaluation on the one
hand and a conscious and more reflective self-evaluation on
the other it is useful to distinguish between two different
constituents of self-esteem [64]: firstly, implicit self-esteem
involving mainly automatic processes [6567] and secondly,
explicit self-esteem, involving higher cognitive processes
[68,69]. Thus, self-esteem is built on (at least) two modes of
information processing [70,71]. Implicit associations with the self
are thought to be more primitive and develop earlier compared to
their explicit counterparts, being closely connected to early social
interactions [8,54,67]. Obviously, cognitive restructuring during
psychotherapy primarily addresses reflective self-evaluation,
which involves higher cognitive processes [7274] and is closely
associated with explicit self-esteem [68,69].
To shed more light on factors that affect explicit and
implicit self-esteem, the present study examined the changes
of explicitly and implicitly measured self-esteem across the
course of an inpatient treatment in individuals with major
depression. This specific treatment has been demonstrated to
reduce symptom distress in depressed individuals [59,60]. In
line with these previous results, we observed significantly
decreasing HADS-D scores across the course of treatment in
the present study. Consequently, we were able to study
changes in self-esteem over an eight week time interval
with significantly decreasing depressiveness. We used the
Rosenberg Self-Esteem Scale as an explicit measure of self-
esteem and, both, the Implicit Association Test for self-
esteem and the Name Letter Test as implicit measures of
self-esteem. All three measures are most frequently used in
self-esteem research [9].
As self-esteem is an important factor in the development
and maintenance of depression [3], our first hypothesis stated

Table 2
Correlations of explicit and implicit self-esteem and depression scores.
Correlations at the beginning of treatment Correlations at the end of treatment
RSES IAT NLT HADS-D RSES IAT NLT HADS-D
RSES 1.00 .03 .18 .55 1.00 .03 .21 .63
IAT 1.00 .09 .13 1.00 .00 .10
NLT 1.00 .05 1.00 .19
HADS-D 1.00 1.00
RSES = Rosenberg Self-Esteem Scale; IAT = Implicit Association Test; NLT = Name Letter Test; HADS-D = Hospital Anxiety and Depression Scale
Depression Score.
p b .001.
 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
that explicit self-esteem will rise during the successful
treatment of depression. In support of this hypothesis, we
observed a significant increase of explicit self-esteem over
time. Furthermore, we argued that (1) increased implicit
self-esteem has been observed after manipulations of threat
[10,29], which has been proposed to be a result of implicit
self-esteem compensation [10] and (2) depressed individuals
are prone to dysfunctional self-schemas [32,33] and
attribution styles [36,37] which is why everyday life bears
frequent threats to their self. Based on this reasoning we
hypothesized that a reduction of depression during treatment
is accompanied by declining processes of implicit self-
esteem compensation. In line with this second hypothesis,
both implicit measures of self-esteem decreased significantly
across the course of treatment.
These results support the notion that ISEC may buffer
depressed individuals' self-esteem. As reviewed above,
depressed individuals reveal lower explicit, but equal
implicit self-esteem in comparison to non-depressed controls
[21,25,26], although also higher [21] or lower [27] implicit
self-esteem has been observed. ISEC can account for these
unexpected and heterogeneous results as it may boost the
state component of implicit self-esteem in depressed to a
level comparable to non-depressed. Depending on the
intensity of the threat as well as the level of depression, it
may not reach or even pass by the level of implicit
self-esteem in non-depressed. For these studies demonstrat-
ing a dissociation of implicit and explicit self-esteem in
depressed but not in non-depressed using a cross-sectional
design, one cannot rule out that sample characteristics not
directly linked to depression may be responsible for
differences in depressed and non-depressed. Because the
present study is first to demonstrate a dissociation of explicit
and implicit self-esteem depressed patients in one single
sample over time, we can exclude that differences in sample
characteristics are mainly responsible for the observed
dissociation.
Note that both implicit scores were positive at the
beginning and end of treatment, indicating a generally
positive implicit self-esteem. In case of the IAT these
positive scores denote that patients made fewer mistakes
when positive and self-related words as well as negative and
other-related words were combined than in conversed
assignments. For the Name Letter Test the positive values
indicate that patients evaluated letters that are part of their
name more positive than do other patients that do not have
these letters in their name. These results are in line with
previous studies that found positive values of implicit
self-esteem in IAT [2127] and NLT [21,26] and may also
be a consequence of ISEC.
However, in the context of contradicting results of
previous studies it is necessary to draw a more elaborate
picture of the possible mechanisms of ISEC, which can be
located within the framework of dual process account. ISEC
is conceptualized as an automatic and unconscious reaction
to severe challenges to self-esteem [10]. That means, this
63
reaction is not activated in any case, but only in cases, when
a perception of a serious self-threat makes it necessary. To
put it in other words there is an individually specific
threshold, above which the initiation of ISEC takes place.
The extent of subjectively experienced self-threat is
determined by several factors:
First, the external situation, which can be perceived as
secure and supporting or challenging and hostile [75].
Thus, for example, at the beginning of a psychiatric
inpatient treatment patients often experience therapeutic
circumstances as far more challenging and threatening as
in the further course of treatment.
Second, the global cognitive vulnerability of an individ-
ual, which is determined by the mental representation of
explicit and implicit attitudes [76]. The implicit attitudes
are mainly automatic and affect driven, the explicit
attitudes belong to the rational system being deliberative
and duty driven [70,77,78]. Both systems interact and
influence behavior to maintain the adequate level of
self-esteem. This highly individual level depends on the
stability of explicit self-esteem, the awareness of current,
past or future threats to self-esteem, the management of
previous self-threats and the associated implicit affective
experiences. The likelihood of feeling seriously chal-
lenged will be greater if explicit self-esteem is fragile
[10,79,80], more threatening situations have been expe-
rienced or are anticipated, and management has been
unsuccessful.
Third, the type of self-threat, which may be relevant or
irrelevant for subjective self-schemas. For example, an
individual defining him- or herself mainly by academic
performance will be more vulnerable to poor grades
compared to an individual, defining him- or herself by
physical appearance [81].
The complex interplay between these factors determines,
whether the critical threshold is reached and ISEC is
initiated. The results of Franck et al. [23] corroborate this
model as depressed individuals with suicidal ideation, that
we would expect to exhibit stronger ISEC, revealed higher
implicit self-esteem than those without suicidal ideation.
Furthermore, in remitted depressed patients [25], the past
experience of low self esteem, poor self esteem management,
and the anticipation of possible recurrence can enhance the
likelihood of ISEC. On the other hand, the experience of
three or more depressive episodes [27] may lead to a change
of implicit appraisal, in the sense that even though several
threatening situations have been experienced, repeated
successful management makes it less threatening and
activation of ISEC less likely. The decrease of implicit
self-esteem after mood induction in formerly depressed
patients [25] can be explained by the fact that the recall of
sad experiences is not synonymous with the recall of
self-threatening experiences. Distraction by other experi-
ences may disengage ISEC.
64 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
Our findings can also be seen within the framework of
dual-process account without the assumption of implicit
self-esteem compensation. Dual-process accounts usually
assume that explicit processing is resource consuming, but
that the processing rules can be learned relatively fast,
whereas implicit processing is effortless but has to be
acquired via repetitive experiences [15,16,77]. While
research has focused on the implicit and explicit vulnerabil-
ity to depression, little is known about the contributions of
these processes in the treatment of and recovery from
depression. If explicit strategies are mainly responsible for
recovery from depression, explicit self-esteem should rise
during the treatment, while implicit self-esteem should rise if
a change in the implicit self-schema is responsible for
improvements. In this line of reasoning, the present results
can be interpreted as supporting the role of explicit
processing in the recovery from depression, because explicit,
but not implicit self-esteem is rising across the course of
therapy. If changes in implicit processing indeed require
repetitive experiences, the present results suggest that much
more experiences have to be made in order to improve
implicit self-schemata than our eight week treatment could
provide. Still, in the present study, implicit self-esteem did
not only fail to increase, but it decreased significantly. Such
impairments in implicit processing may be a consequence of
changes in well-learned implicit memory structures. Indeed
it has been demonstrated that learning changed implicit
representations usually leads to reduced output [82,83]. As
an example, imagine changes to a well learned mostly
automatic and effortless process like driving a car. If you are
used to drive a car with manual gear shift, changing to a car
with automatic gearbox may temporarily cause difficulties,
deceleration, and mistakes, although an automatic gear
system may be regarded as easier to learn for a beginner.
Likewise, a depressed individual that makes experiences of
self-efficacy due to therapeutic interventions may have to
integrate this new information in a less favorable implicit
self-schema. This may cause a weakening of old represen-
tations in the beginning yielding impaired performance in
tasks like the IAT or NLT. Thus one may expect that positive
experiences can cause changes to a less positive implicit
self-concept thereby interfering with the well learned more
automatic processing until the changes have been consoli-
dated. In the light of this interpretation, it is primarily explicit
processing that is responsible for the immediate recovery during
the treatment of depression, while implicit processing may
possess relevance for later phases of stabilization. This
alternative explanation may be regarded as more parsimonious
because it does not require the assumption of self-defensive
needs or processes. On the other hand, this account has
difficulties explaining positive implicit self esteem in depressed
individuals, which has been found in several studies [21,2426].
With regard to our findings, some methodological issues
should be discussed. Neither at the beginning nor at the end
of treatment any of the three measures of self-esteem
correlated significantly with each other. This complies with
the results of meta-analyses that find very small to non-
existent correlations between implicit and explicit measures
of self-esteem as well as between different measures of
implicit self-esteem [8,9].
After all, the strong negative correlation of explicit
self-esteem with depression corroborated the validity of the
Rosenberg Self-Esteem Scale. Although we did not find
significant correlations of implicit and explicit measures, we
observed strong correlations across time for each of the
implicit measures which lends support to a reasonable extent
of reliability and stability. An alternative explanation for the
decreasing implicit self-esteem may be that reduced
depression in our study did influence processing speed
which may have influenced the reaction times in the IAT.
However, this explanation cannot account for the results
of the Name-Letter Task.
In conclusion it is rather unlikely that implicit and explicit
measures mirror the same aspects of self-esteem, because our
data showed a clear dissociation of both measures. If indeed
implicit measures of self-esteem are affected by processes
of self-esteem compensation, one cannot expect a strong
correlation with explicit self-esteem. An individual with high
self-esteem in a situation that does not threaten the self
will reveal high explicit but low implicit self-esteem. If
this individual is exposed to a self-threatening situation, the
threat to self-esteem will automatically be compensated for,
and high implicit and high explicit self-esteem will be
observed. Despite the dissociation of implicit and explicit
measures of self-esteem, we do not assume that both
procedures are affected by completely disjunct processes,
because some studies find significant correlations between
both approaches. Moreover, explicit measures of self-esteem
have been demonstrated to increase under conditions of
threat [8486], but also the reversed pattern was observed
[87,88]. There seems to be a considerable overlap of, but also
significant differences between implicit and explicit measures of
self-esteem. More research is needed to specify, which processes
affect each of the two measures under which conditions.
A major limitation of the present work is the absence of a
non-depressed control group. Hence we do not know
whether implicit and explicit self-esteem is higher, lower
or on an equal level compared to a healthy control group.
Nevertheless, the dissociation of implicit and explicit
measures of self-esteem remains a significant and valid
result, even without control group. A second limitation is
that we did not use a measure of self-threat that would allow
to corroborate our assumption of elevated self-threat in our
depressed sample. However, it is very difficult to measure
self-threat in all its significant facets, as it embraces relevant
aspects not consciously retrievable. A third limitation is that
we failed to observe a significant correlation of the two
measures of implicit self-esteem. Also other studies using
more than one measure of implicit self-esteem found that
these different measures of implicit self-esteem were affected
similarly, although they have repeatedly been demonstrated
to be unrelated [42,89,90]. One may speculate that different
 I. Wegener et al. / Comprehensive Psychiatry 58 (2015) 5767
implicit measures of self-esteem tap different aspects of implicit
self-esteem or that methodological differences of the tasks (e.g.,
fast vs. slow evaluations in IAT vs. NLT) hinder correlations to
reach significance, especially in smaller samples.
5. Conclusions
The findings underline the importance of implicit self-
esteem compensation in depressed patients as a relevant
implicit mechanism for stabilization that may undergo
specific changes during treatment. Within the dual process
account for cognitive vulnerability in depression, ISEC can
explain previously not well understood findings such as a
higher implicit self-esteem in depressed patients. Measures
of implicit self-esteem may help to gain more insight into
these processes of protecting self-esteem, thereby hopefully
paving the way to optimize the treatment of depression.
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