Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms
Mo rtberg E (2013) Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association
with Social Anxiety and Depressive Symptoms. PLoS ONE 8(4): e61713. doi:10.1371/journal.pone.0061713
Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms
Erik Hedman 0
Peter Stro m 0
Angela Stu nkel 0
Ewa Mo rtberg 0
Qiyong Gong, West China Hospital of Sichuan University, China
0 1 Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden, 2 Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden, 3 Department of Psychology, Stockholm University , Stockholm , Sweden
Social anxiety disorder (SAD), characterized by fear of being scrutinized by others, has features that that are closely linked to the concept of shame. Despite this, it remains to be investigated whether shame is elevated in persons with SAD, and if cognitive behavior therapy (CBT) for SAD could reduce shame experience. In the present study, we focused on internal shame, i.e. the type of shame that pertains to how we judge ourselves. Although guilt is distinctly different from shame, we also viewed it as important to investigate its role in SAD as the two emotions are highly correlated. The aim of this study was to investigate: (I) if persons with SAD differ from healthy controls on shame and guilt, (II) if shame, guilt, depressive symptoms, and social anxiety are associated in persons with SAD, and (III) if CBT can reduce internal shame in patients with SAD. Firstly, we conducted a case-control study comparing a sample with SAD (n = 67) with two samples of healthy controls, a main sample (n = 72) and a replication sample (n = 22). Secondly, all participants with SAD were treated with CBT and shame, measured with the Test of Self-Conscious affect, was assessed before and after treatment. The results showed that shame was elevated in person with SAD compared to the control replication sample, but not to the main control sample. In addition, shame, social anxiety, and depressive symptoms were significantly associated among participants with SAD. After CBT, participants with SAD had significantly reduced their shame (Cohen's d = 0.44). Guilt was unrelated to social anxiety. We conclude that shame and social anxiety are associated and that it is likely that persons with SAD are more prone to experience shame than persons without SAD. Also, CBT is associated with shame reduction in the treatment of SAD.
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Social anxiety disorder (SAD) is characterized by a debilitating
fear of being scrutinized by others and avoidance of social events
that evoke this fear [1]. It is the one of the most common
psychiatric disorders and associated with substantial impairment
and an increased risk of developing other psychological problems
[2,3]. Many features of SAD, such as fear of speaking in front of an
audience, are highly prevalent also in the normal population [4].
From an evolutionary perspective social anxiety probably plays an
important role in preventing the individual to act in ways that
could put them at risk of being excluded from the social
community, and has therefore been described as the fear of
exclusion [5].
Several aspects of social anxiety and SAD are linked to the
concept of shame. Shame can be defined as an affect involving
perceptions that others view oneself as having negative personal
characteristics or that one has engaged in behaviors that are
unattractive [6,7]. This affective state is made possible by the
human complex ability of imagining how one is represented in the
minds of others and could be viewed as a signal that one is at risk
of losing social rank or being rejected [8]. The ultimate function of
shame is to motivate behaviors that are appealing to others, signal
submission, and limit possible social damage [9,10]. The
similarities of shame and guilt are often underscored, but there
is a clear distinction between the two [6,11]. Guilt is largely
unrelated to the perception of others and relates to specific actions
that violates others rights according to ones own view, and
promotes remorse and restorative behaviors [12]. Shame on the
other hand, is entirely related to ones perceived attractiveness,
and is to a larger extent therefore directed towards the self rather
than to specific behaviors [12]. An important aspect of shame is
that it can be external or internal [13]. External shame refers to
the affect that is based on how one is perceived by others. This is
sometimes referred to as stigma awareness and concerns aspects of
ones actions that could lead to rejection or criticism, if they were
known to others [13]. Internal shame could be defined as shame
based on how the individual views him- or herself. As expressed by
Matos et al. [10], internal shame refers to when we are both the
judge and the judged. As pointed o (...truncated)