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British Journal of Clinical Psychology (2014), 53, 299–314 © 2014 The British Psychological Society www.wileyonlinelibrary.com
Self-conscious emotions in worry and generalized anxiety disorder Michelle Schoenleber*, Philip I. Chow and Howard Berenbaum University of Illinois at Urbana-Champaign, Champaign, Illinois, USA Objectives. Current theories regarding worry and generalized anxiety disorder (GAD) highlight the potential avoidance functions of worry, and it has been suggested that worry functions to avoid self-conscious emotions in particular. Therefore, the present study examined the roles of proneness and aversion to self-conscious emotions in worry and GAD. Design. Cross-sectional data from two samples were collected: (1) a sample of 726 undergraduates, and (2) a selected sample of 51 community members, 37.3% of whom met DSM-IV criteria for GAD. Zero-order correlations and hierarchical multiple regression analyses were used to examine associations of self-conscious emotion constructs to worry and GAD. Method. Proneness to guilt and shame (propensities for experiencing guilt and shame, respectively) were assessed via the Test of Self-Conscious Affect-3. Aversion to guilt and shame (perceptions of guilt and shame, respectively, as especially painful, undesirable emotions) were assessed using the Guilt Aversion Assessment and Shame-Aversive Reactions Questionnaire, respectively. Worry was assessed using the Penn State Worry Questionnaire, and GAD was assessed via the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Results. Correlations indicated positive associations between self-conscious emotion constructs and worry/GAD. However, in the selected community sample, regression analyses indicated that only shame aversion was positively associated with worry/GAD, over and above all other self-conscious emotion constructs and depression. Conclusions. Results suggest a prominent role for an intolerance for shame in worry and GAD, which is broadly consistent with psychological models of worry. Future directions for research and clinical implications are discussed.
Practitioner points
Positive clinical implications Evidence supporting the theorized importance of self-conscious emotions in worry and GAD. Specifically highlights the need to address intolerance for shame in treatment.
Limitations Small sample size in Study 2. Use of cross-sectional data.
*Correspondence should be addressed to Michelle Schoenleber, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA (email: [email protected]). DOI:10.1111/bjc.12047
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Most psychological models of worry and generalized anxiety disorder (GAD) focus on the probable avoidance functions of worry. The Cognitive Avoidance Model (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004) asserts that worry, a core characteristic of GAD (American Psychiatric Association [APA], 2000, 2013), is used to prevent and/or prepare for unpleasant events, as well as to dampen the somatic arousal engendered by feared contexts. Similarly, others have suggested that worry serves a broad experiential avoidance function, motivated by discomfort with unpleasant internal experiences in general (e.g., thoughts, feelings, sensations; see Roemer, Salters, Raffa, & Orsillo, 2005). Consistent with these models, individuals with elevated GAD symptomatology often endorse positive beliefs about worry (e.g., Borkovec & Roemer, 1995), and experiential avoidance is positively associated with worry/GAD (e.g., Roemer et al., 2005). However, worry is itself associated with unpleasant emotional experience (e.g., trait negative affect, general distress; Watkins, 2008; Lee, Orsillo, Roemer, & Allen, 2010), suggesting that worry may not function to avoid distress altogether. With this in mind, Newman and Llera (2011) extended these existing theories in the Contrast Avoidance Model. Reviewing the findings regarding worry and negative emotionality (e.g., reactivity to unpleasant emotional stimuli), they posited that worry sustains distress so that individuals can avoid experiencing a shift from a relatively positive emotional state to a more negative emotional state. Indeed, individuals with elevated GAD symptomatology report feeling better able to cope with unpleasant emotional stimuli if they had previously been worrying, but less able to cope if they had been relaxing (Llera & Newman, 2010). Furthermore, individuals with elevated worry/GAD symptomatology report using worry to distract themselves from even more distressing topics (Borkovec & Roemer, 1995; Freeston, Rheaume, Letarte, Dugas, & Ladouceur, 1994). Drawing on all of these models, the present investigation examined the associations between worry/GAD and emotion-related personality traits that may motivate the use of worry as an avoidance strategy. First, trait propensities to experience certain unpleasant emotions readily across situations (i.e., proneness for certain emotions) may increase the use of worry; emotions that pose the greatest threat of elicitation also pose the greatest threat of creating increases in distress and/or a negative emotional contrast. Second, trait tendencies to perceive of certain emotions as especially painful and undesirable (i.e., aversion to certain emotions) may increase the use of worry; emotions that are particularly difficult to tolerate are those that likely increase the use of avoidance strategies in general, including worry. This study focused on the role of traits related to two unpleasant self-conscious emotions – guilt and shame – in worry and GAD. The capacity for self-conscious emotions develops around age two, as children acquire self-awareness and the ability to evaluate self-representations (e.g., Lewis, Sullivan, Stanger, & Weiss, 1989), and are thus considered cognitively complex emotions. Furthermore, these emotions are sometimes thought of as ‘social’ or ‘moral’ emotions, as they can be elicited by failing to live up to personal standards or shared social conventions and may motivate socially appropriate or moral behaviour (see Tangney, Stuewig, & Mashek, 2007, for review). However, guilt and shame are far from synonymous emotions. Drawing on the definitions provided in Lewis’ (1971) seminal work, guilt is defined as an emotion elicited when people negatively evaluate what they do and that often leads to efforts to apologize or make reparation; by comparison, shame is defined as an emotion elicited when people negatively evaluate who they are and that motivates social avoidance behaviour. There are several theoretical reasons to expect that self-conscious emotions, in particular, may be associated with worry and GAD. To begin with, it has previously been
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suggested that self-conscious emotions are prominent among those that individuals are trying to avoid by worrying (Freeston et al., 1994; Gosselin et al., 2003). Indeed, if individuals believe that worry is helping them prepare for or prevent feared outcomes, then they may feel less guilty or ashamed when the outcome does come true. In other words, the feared outcome may have happened, but at least they tried to stop it (so they may believe). Or, from a contrast avoidance perspective, at least they had readied themselves for the distress they knew the feared outcome would cause. Moreover, GAD has been theorized and also found to be associated with interpersonal problems (e.g., Borkovec, Newman, Pincus, & Lytle, 2002), and as mentioned above, self-conscious emotions are often social in nature (see Tangney & Dearing, 2002). Additionally, research also supports the potential relevance of self-conscious emotion to worry, albeit somewhat indirectly. For example, elevated worry is associated with diminished self-esteem, lower perceived competence, and higher personal inadequacy/incompetence (Berenbaum, Thompson, & Bredemeier, 2007; Breitholtz, Johansson, & Ost, 1999; Davey & Levy, 1999; Meyer, Miller, Metzger, & Borkovec, 1990), all of which may elicit guilt and/or shame. In fact, drawing on that research, it has been proposed elsewhere that diminished perceptions of competence – which may elicit these self-conscious emotions – play an important role in the genesis of worry (see Berenbaum, 2010). To date, only one study has examined the importance of propensities for self-conscious emotion to worry, and none have considered their importance to GAD symptoms. Fergus and colleagues (Fergus, Valentiner, McGrath, & Jencius, 2010) examined guilt- and shame-proneness in a sample of 127 outpatients (28 of whom had a diagnosis of GAD) who received intensive treatment at an anxiety disorders clinic. Results indicated that self-reported worry on the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990) was positively associated with shame-proneness but was not associated with guilt-proneness. Furthermore, greater changes in worry from pre- to post-treatment were associated with larger changes in shame-proneness. Similarly, only one previous study has considered the importance of constructs similar to aversions to self-conscious emotions to GAD symptomatology. Llera and Newman (2010) found that individuals in a GAD analogue group (based on self-reported GAD symptoms on the Generalized Anxiety Disorder Questionnaire-IV; Newman et al., 2002) were more likely to perceive of ‘guilt’ as a threatening emotion than were individuals in a non-anxious control group. However, as the terms ‘guilt’ and ‘shame’ are often used interchangeably in lay language, it remains an open question whether either or both of these unpleasant self-conscious emotions is perceived to be threatening. The present study is therefore additionally the first to consider both aversions to and propensities for self-conscious emotions in relation to worry/GAD at the same time. Importantly, guilt and shame are often differentially associated with psychological problems. Although guilt is often assumed to promote psychological problems because it is an unpleasant emotion and sometimes demonstrates significant positive bivariate correlations with measures of psychological distress (e.g., Tangney, Wagner, & Gramzow, 1992), research has consistently shown that shame-free guilt tends to be associated with prosocial behaviours and good interpersonal functioning (e.g., de Hooge, Zeelenberg, & Breugelmans, 2007; Leith & Baumeister, 1998; Tangney, 1995); in other words, the relationships between guilt and psychological problems become non-significant after taking into account the association between guilt and shame. The same is not true of shame, however. Shame is positively associated with a wide variety of psychological problems, even after taking guilt into account (e.g., Tangney et al., 1992). Indeed, the differential action tendencies associated with guilt and shame – approach versus
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avoidance, respectively – suggest that shame, but not guilt, might be particularly important to worry. Thus, although theories and research regarding worry generally do not differentiate between guilt and shame (see Fergus et al., 2010, as an exception), the self-conscious emotion literature suggests that only shame will be positively associated with worry/GAD. The present investigation therefore examined propensities and intolerances for each of these emotions separately. Additionally, several studies have found that worry/GAD is associated with greater tendencies toward depression. Indeed, there are high rates of comorbidity between GAD and major depressive disorder (MDD; e.g., Brown & Barlow, 1992; Sanderson, Beck, & Beck, 1990), and elevations in worry and GAD symptomatology are positively associated with depression (e.g., Olatunji, Broman-Fulks, Bergman, Green, & Zlomke, 2010). Moreover, depression is itself associated with unpleasant self-conscious emotion (see e.g., Kim, Thibodeau, & Jorgensen, 2011) and includes feelings of guilt and worthlessness (suggestive of shame) among its criteria (APA, 2000). Thus, it is important that research on the roles of self-conscious emotion in worry/GAD take depressive symptomatology into consideration as well. In summary, the present investigation examined the relevance of proneness for guilt and shame, as well as aversion to guilt and shame, to worry and GAD symptoms. We hypothesized that elevations in worry and GAD symptoms would be associated with higher levels of both shame-proneness and shame aversion. However, we expected that worry and GAD would show no association with guilt-proneness or guilt aversion. To consider the specificity of the associations between worry/GAD and these self-conscious emotion constructs, we additionally explored the associations between depression and propensities and intolerances for self-conscious emotions. As the present research was the first to consider the relevance of guilt and shame aversions to any form of anxiety disorder, we began by testing these hypotheses in a large undergraduate sample. Subsequently, we sought to replicate and extend the findings of our initial study by examining proneness and aversion to self-conscious emotions in a selected community sample.
STUDY 1 Method Participants Participants in Study 1 were 726 undergraduates (69.3% female) with a mean age of 19.6 years (SD = 1.3). The majority of this sample (65.9%) described themselves as White/Non-Hispanic, followed by 15.0% Asian American, 6.5% Hispanic/Latino(a), 4.5% African American, 3.3% Multiracial, and with 4.8% describing themselves as ‘Other.’ All participants completed a voluntary informed consent at the start of the session and received course credit for participation. Measures Shame- and guilt-proneness We used the guilt and shame items from the Test of Self-Conscious Affect-3 (Tangney, Dearing, Wagner, & Gramzow, 2000) to assess participants’ tendencies to experience shame and guilt, respectively, readily and often. The TOSCA-3 presents participants with 16 brief scenarios that could potentially elicit guilt- and/or shame-related responses (e.g.,
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‘While out with a group of friends, you make fun of a friend who’s not there’). Using a 5-point Likert scale, participants indicate the extent to which they would experience a possible guilt response (‘You would apologize and talk about the person’s good points’), as well as a possible shame response (‘You would feel small...like a rat’). The TOSCA-3 guilt- and shame proneness scales have been shown to be valid and reliable (e.g., Tangney, Wagner, Fletcher, & Gramzow, 1992). Cronbach’s alpha was .70 for the guilt-proneness scale and was .81 for the shame-proneness scale. Guilt aversion The Guilt Aversion Assessment (GuAvA) was used to measure individuals’ perceptions of guilt as particularly distressing and unwanted (Schoenleber & Berenbaum, 2012). Participants indicated their agreement with each of 16 items (e.g., ‘I hate feeling accountable after I’ve done something bad’) on a 7-point scale. Guilt aversion shows expected positive associations with shame aversion and with guilt- and shame-proneness, both in previous work (Manjrekar, Schoenleber, & Mu, 2013; Schoenleber & Berenbaum, 2012; Schoenleber et al., 2014) and in the present sample, as can be seen in Table 1. The GuAvA has also shown expected relationships to trait affect, experiential avoidance, and psychological problems, as well as having good internal consistency (see Manjrekar et al., 2013; Schoenleber & Berenbaum, 2012; Schoenleber et al., 2014). Cronbach’s alpha for the GuAvA was .87 in this study. Shame aversion Participants completed the Shame-Aversive Reactions Questionnaire (ShARQ; Schoenleber & Berenbaum, 2010), which measures the degree to which shame is perceived to be an especially painful and undesirable emotion. Using a 1–7 scale, participants indicate their agreement with each of 14 statements (e.g., ‘Feeling inadequate troubles me more than anything else’). The ShARQ has displayed good convergent validity and internal consistency in previous research (see Schoenleber & Berenbaum, 2010, 2012; Schoenleber, Berenbaum, & Motl, 2014). Internal consistency for the ShARQ was also good in the present sample (a = .83).
Worry The PSWQ (Meyer et al., 1990) was used to assess the tendency to worry in both samples. On the PSWQ, participants rated 16 statements (e.g., ‘My worries overwhelm me’) with regard to how typical each is of them on a 1 to 5 scale. Previous studies indicate that the PSWQ has good convergent validity and test–retest reliability (e.g., Meyer et al., 1990). In the present study, Cronbach’s alpha was .94. Anhedonic depression Participants completed the anhedonic depression subscale of the Mood and Anxiety Symptoms Questionnaire (MASQ; Watson & Clark, 1991). Twenty-one items rated on a 5-point Likert scale are used to assess the degree to which individuals experience depression-related deficits in pleasure; the item assessing suicidal ideation was not included. The MASQ anhedonic depression subscale displays good validity and reliability (Watson et al., 1995), and internal consistency was also good in the present study (a = .93).
.35** –
– .38** .19** .25** –
–
Guilt Aversion
.25** .01
Guilt-Proneness
Note. M, Mean; SD, Standard Deviation; Min, Minimum; Max, Maximum. **p < .01.
Worry Anhedonic Depression Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
Anhedonic Depression
Worry
.33** .41** –
.42** .31**
Shame-Proneness
.04 .36** .41** –
.44** .43**
Shame Aversion
Table 1. Descriptive statistics for and relationships among worry, anhedonic depression, and self-conscious emotions for Study 1
63.5 72.4 45.4 51.4
49.7 48.2
M
6.9 15.4 9.7 12.4
13.7 13.7
SD
38 21 17 19
16 21
Min
80 110 73 87
80 96
Max
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Results To begin with, we explored the extent to which our undergraduate sample evidenced potentially important levels of worry and anhedonic depression. A total of 110 participants (15.2%) had scores on the PSWQ of at least 65, which was the mean score found for a clinical sample of individuals with GAD (SD = 10; see Meyer et al., 1990); an additional 148 participants (20.4%) were within 1 SD below the clinical sample’s mean score. A total of 81 participants (11.2%) had anhedonic depression scores on the MASQ of at least 65.5, which was the mean score found for a patient sample (SD = 14.8; see Watson et al., 1995); an additional 187 participants (25.8%) were within 1 SD below the patient sample’s mean score. Thus, the present undergraduate sample included a wide range of worry and anhedonic depression severity, including a substantial number of participants evidencing concerns similar to those of generally more severe samples. Next, we investigated whether guilt and/or shame constructs were associated with worry. Descriptive statistics for and relationships among worry, anhedonic depression, and self-conscious emotion constructs are presented in Table 1. As shown in Table 1, worry was positively associated with anhedonic depression and all self-conscious emotion constructs. Following previous research (e.g., Fergus et al., 2010), we next considered the incremental predictive utility of guilt and shame constructs, over and above one another as well as anhedonic depression. Specifically, we ran a hierarchical multiple regression analysis with anhedonic depression entered in Step 1 and all of the self-conscious emotion constructs entered simultaneously in Step 2.1 As shown in the left portion of Table 2, in Step 1 higher scores for anhedonic depression were associated with greater worry. In Step 2, all self-conscious emotion constructs were also positively associated with worry. Interestingly, shame aversion exhibited the strongest association with worry. For the purpose of comparison, we ran a regression analysis similar to that above, but with worry in Step 1 and with anhedonic depression as the outcome variable, as shown in Table 2. As with worry, in Step 2 elevations in anhedonic depression were associated with higher shame-proneness and shame aversion. However, unlike worry, anhedonic depression was negatively associated with guilt-proneness and not associated with guilt aversion.2
STUDY 2 Method Participants Fifty-one individuals were recruited from a small Midwestern city to participate in a larger research project, one goal of which was to examine the associations between self-conscious emotions and worry/GAD.3 Specifically, individuals were recruited via 1 All of the hierarchical multiple regression analyses presented in this article were also run with an additional fourth step in which we entered the shame-proneness 9 shame aversion and the guilt-proneness 9 guilt aversion interaction terms. None of the interactions in any of the regression analyses involving worry or GAD symptoms were significant. 2 In addition, there was a significant shame-proneness x shame aversion interaction (b = .07, p < .05). Simple slopes analyses indicated that although there was a significant positive association between shame-proneness and anhedonic depression when shame aversion was high (b = .21, p < .01), this association fell just short of statistical significance when shame aversion was low (b = .10, p = .052). 3 No other inclusion/exclusion criteria were employed at the time of recruitment; however, data from two additional individuals were not included in the present investigation due to the presence of symptoms of psychosis and/or mania.
Note. *p < .05; **p < .01.
Step 1 Anhedonic Depression/MDD Symptoms or GAD Symptoms Step 2 Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
.15** .17** .16** .23**
.35**
b
Worry
.21**
.12**
DR2
.12** .03 .15** .30**
.35**
b
.12**
.12**
DR2
Anhedonic Depression
Study 1 (N = 726)
.03 .07 .08 .59**
.26
b
Worry
.45**
.07
DR2
.14 .23 .04 .40*
.30*
b
.28**
.09*
DR2
GAD Symptoms
Study 2 (N = 51)
Table 2. Summary of hierarchical multiple regression analyses for worry, generalized anxiety disorder, and major depressive disorder
.00 .22 .46** .23
.30*
b
.09
.09*
DR2
MDD Symptoms
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public advertisements seeking individuals who worry frequently. Participants were 20– 61 years old (M = 36.9; SD = 12.8) and 66.7% were female. Consistent with the population characteristics of the local community, the majority of participants (72.5%) were White/Non-Hispanic, followed by 9.8% African American, 7.8% Asian American, 5.9% Multiracial, and 3.9% describing themselves as ‘Other.’ All participants completed a voluntary informed consent at the start of the session and received monetary compensation for their participation. Measures Self-conscious emotions and worry As with Study 1, participants in Study 2 completed the following: (1) TOSCA-3 (guilt-proneness a = .77; shame-proneness a = .81), (2) GuAvA (a = .87), (3) ShARQ (a = .88), and (4) PSWQ (a = .94). Anxiety and mood disorders Additionally, all participants in Study 2 were interviewed using the anxiety and mood disorder modules of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002) to assess symptoms of Axis I anxiety and mood disorders. Given the a priori hypotheses for this study, we were interested primarily in GAD, as well as in MDD as a covariate and indicator of general distress. All interviews were conducted by the first and second authors, each of whom were advanced graduate students with at least 2 years of training in the use of the SCID-I for clinical and research purposes. Each criterion was rated on a scale from 0 to 2 with 0 indicating the absence of a given symptom, 1 indicating subthreshold presence of the symptom, and 2 indicating that the diagnostic criterion was met. In addition to determining whether each participant met criteria for anxiety or mood disorders, we also calculated a weighted symptom count for GAD and lifetime MDD. All interviews were audiotaped, and 15 were randomly selected for secondary ratings; inter-rater reliability was measured using the intraclass correlation following Shrout and Fleiss (1979), treating raters as random effects and the individual rater as the unit of reliability. The intraclass correlation was .98 for GAD and .99 for MDD.
Results First, we examined the extent to which this selected, community-based sample evidenced clinically significant levels of GAD and other forms of psychopathology. Descriptive statistics are presented in Table 3. Consistent with our recruitment advertisements seeking individuals who worry, 30 participants met at least one diagnostic criterion of GAD, with 19 participants (37.3%) displaying sufficient symptoms to meet criteria for a diagnosis of that disorder. Thus, the present sample contained a relatively wide range of GAD symptom severity, with a significant portion of the sample reporting clinically important GAD symptoms. Lifetime symptoms of MDD were also common. Although only two participants were currently experiencing a major depressive episode, 24 (47.1%) had experienced at least one episode during their lifetime. Of these 24 participants, 10 met criteria for GAD as well. Many participants met criteria for other anxiety disorders: 21.6% for social phobia, 7.8% for obsessive-compulsive disorder, and 5.9% for panic disorder, specific phobia, and/or posttraumatic stress disorder.
–
.79** –
GAD Symptoms .28* .25 –
MDD Symptoms .09 .20 .24* –
Guilt-Proneness
Note. M, Mean; SD, Standard Deviation; Min, Minimum; Max, Maximum. *p < .05; **p < .01.
Worry GAD Symptoms MDD Symptoms Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
Worry .34** .41** .07 .35** –
Guilt Aversion .53** .45** .33* .41** .60** –
Shame-Proneness .68** .49** .13 .06 .37** .66** –
Shame Aversion
54.7 7.0 7.4 66.9 70.6 49.2 58.7
M
Table 3. Descriptive statistics for and relationships among worry, GAD and MDD symptoms, and self-conscious emotions for Study 2
14.5 5.8 7.2 7.5 16.5 11.0 14.5
SD
25 0 0 42 33 21 21
Min
75 16 18 77 106 69 86
Max
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Next, we investigated whether guilt and/or shame constructs were associated with worry and/or GAD symptoms. As shown in Table 3, PSWQ worry and SCID-I weighted GAD symptom counts were both positively associated with shame-proneness, shame aversion, and guilt aversion. However, guilt-proneness was not associated with either worry or GAD symptoms. Not surprisingly, individuals with GAD also reported significantly greater shame-proneness, shame aversion, and guilt aversion than did individuals who did not meet diagnostic criteria for GAD, ts(49) = 3.18, 3.56, and 2.72, all ps ≤ .01, respectively. Next, as in Study 1, we examined the incremental predictive utility of all self-conscious emotion constructs over and above one another, as well as over and above MDD. A pair of hierarchical multiple regression analyses were run, entering MDD weighted symptom count in Step 1 and all self-conscious emotion constructs in Step 2. As shown in the right portion of Table 2, in Step 1 of these analyses, although the association between MDD and PSWQ worry fell short of significance (b = .26, p = .064), the association between MDD and SCID-I GAD was statistically significant. In Step 2 of these analyses, and consistent with the fact that it exhibited the strongest relationship to worry in Study 1, greater shame aversion was associated with elevations in PSWQ worry (b = .59, p < .01) and greater SCID-I GAD (b = .40, p < .05); none of the remaining self-conscious emotion constructs were significantly associated with these outcomes. Finally, we conducted another regression analysis similar to that above, but using SCID-I GAD symptom scores in Step 1 and MDD symptoms as the outcome variable, as shown in Table 2. The results in Step 2 of this analysis differed from those for GAD symptoms in multiple ways. First, although statistically non-significant, the association between MDD symptoms and guilt aversion was negative, whereas that between GAD symptoms and guilt aversion was of equal magnitude but positive. Second, unlike GAD symptoms, the association between MDD symptoms and shame aversion was both negative and statistically non-significant. Third, the association between MDD and shame-proneness was statistically significant, with elevations in MDD symptoms being associated with higher levels of shame-proneness.
GENERAL DISCUSSION Results were generally consistent with our predictions, overall supporting a role for self-conscious emotions in worry and GAD symptoms. First, in Study 1 all self-conscious emotion constructs were positively associated with worry, over and above anhedonic depression. Second, using a selected community sample in Study 2, shame aversion emerged as the only self-conscious emotion construct significantly associated with worry and GAD symptoms after also taking MDD symptoms into account. Thus, our findings indicate that greater intolerance for shame, in particular, may be especially relevant to elevations in worry and GAD symptoms. Additionally, that shame aversion’s associations to worry and GAD remained significant even after taking levels of depressive symptomatology into account suggests that the relevance of shame aversion to worry/GAD is not attributable to other Axis I disorders related to shame or to the similarities between depression and anxiety (e.g., Mineka, Watson, & Clark, 1998). Importantly, our findings are consistent with existing models of worry/GAD that focus on the avoidance functions of worry (e.g., Borkovec et al., 2004; Newman & Llera, 2011; Roemer et al., 2005), as well as with previous suggestions that self-conscious emotions, in particular, are the target of such avoidance (e.g., Freeston et al., 1994; Gosselin et al., 2003). Indeed, it is reasonable to assume that aversions to emotion motivate behavioural
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attempts (e.g., worrying) to reduce the likelihood of those emotions. Our results suggest that an aversion to shame, specifically, may motivate individuals to use worry in order to avoid that particular emotional state. Admittedly, however, the present study cannot directly address whether shame aversion motivates worry or whether worry actually down-regulates shame or shame-related emotional contrasts. It remains an open question whether worry is at all effective as a shame regulation strategy, one that we hope will be considered in future investigations using experimental designs. As mentioned above, ours is the first study to examine guilt aversion and shame aversion, separately and specifically, in worry and GAD. Although one previous study (Llera & Newman, 2010) found that individuals in a GAD analogue group reported higher perceptions of ‘guilt’ as threatening than did a non-anxious control group, that study could not speak to the potentially differential importance of guilt and shame to worry/ GAD. Additionally, although likely related concepts, perceived threat is not necessarily synonymous with aversion. As such, the present study extends this past research, indicating that it is the tendency to perceive of shame, specifically, as painful and undesirable that is associated with higher levels of worry and GAD symptoms. Our results also extend those of the one existing study that examined proneness to self-conscious emotions in relation to worry (Fergus et al., 2010). Partial correlations in that study showed that shame-proneness was positively associated with worry after taking guilt-proneness into account, but the opposite was not true. Post-hoc analyses in our samples revealed a similar prominent importance for shame-proneness over guilt-proneness; partial correlations for our community sample replicated the findings of Fergus et al. (for worry and GAD, respectively: shame-proneness, rs = .56 and .42, ps < .001; guilt-proneness, rs = -.11 and .11, ps = n.s.). Similarly, in our undergraduate sample the partial correlation for shame-proneness (r = .37, p < .001) was significantly greater than the partial correlation for guilt-proneness (r = .13, p < .001; t(723) = 5.96, p < .001). Our data therefore support the assertion that shame-proneness is important in worry and GAD over and above guilt-proneness. However, a propensity for shame may not be as relevant to worry and GAD as is an aversion to that emotion. By comparison, shame-proneness continued to be positively associated with anhedonic depression in Study 1 and with MDD symptoms in Study 2 even after taking shame aversion into account. In fact, whereas shame aversion demonstrated an inconsistent relationship to depression across our two samples, greater propensities for shame were associated with elevations in depressive symptomatology among both undergraduates and community members. Thus, although they are often co-occurring problems, worry/GAD and depression may be distinguishable in part by their differential relationships to shame-related constructs. Our findings must be interpreted in light of the study’s limitations, which also highlight important directions for future research. First, both of our samples included individuals who reported significant concerns related to worry (15.2% of undergraduates endorsing levels of worry at or above the mean of a clinical sample; 37.3% of community members endorsing symptoms of GAD sufficient for diagnosis). However, future studies would benefit from the use of clinical samples that may include an even greater number of individuals experiencing more serious distress and impairment as a result of frequent, under-controlled worry. A second limitation of the present research was that our studies did not include broader measures of emotional intolerance (e.g., experiential avoidance) and/or measures of aversion to other specific emotions. For example, existing research indicates that fears of depression are positively associated with worry/GAD (Roemer et al., 2005; Turk,
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Heimberg, Luterek, Mennin, & Fresco, 2005) and distinguish between individuals in a GAD clinical sample versus a non-clinical comparison group (Roemer et al., 2005). Perceptions of sadness as threatening also distinguish between individuals high versus low on self-report measures of GAD symptoms (Llera & Newman, 2010). Given this research, it will be important for future studies to consider whether shame aversion remains an important correlate of worry/GAD over and above an aversion to depression. Furthermore, some models of worry/GAD suggest that a broader form of intolerance – intolerance of uncertainty – is central in perpetuating the use of worry as a cognitive avoidance strategy (e.g., Dugas, Gagnon, Ladouceur, & Freeston, 1998). It remains to be seen whether intolerances for specific emotional experiences are relevant to worry/GAD above and beyond discomfort with ambiguous situations more generally. Although our results indicate that shame aversion is relevant to worry/GAD over and above a number of other potential explanatory constructs, inclusion of measures such as the Affect Control Scale (Williams, Chambless, & Ahrens, 1997) and Intolerance of Uncertainty scale (Buhr & Dugas, 2002) would provide a more stringent test of our hypotheses. A third limitation is that the present study only considered proneness and aversion to guilt and shame in worry/GAD and anhedonic depression/MDD; however, it is possible that some or all of these constructs are also relevant for understanding other psychological problems. In particular, it would be useful for future studies to consider the relative roles of proneness and aversion to other forms of psychopathology, such as social phobia and posttraumatic stress disorder, both of which are theoretically (e.g., Clark & Wells, 1995; Resick & Schnicke, 1992) and empirically (e.g., Fergus et al., 2010; Leskela, Dieperink, & Thuras, 2002) associated with self-conscious emotions. Further research on proneness and aversion to self-conscious emotions in depression is also warranted, especially given the inconsistency in our findings regarding shame aversion. Our findings may be partially attributable to measure-related differences across our two studies; the measure in Study 1 focused on one particular feature of depression – loss of interest/diminished capacity for pleasure – whereas the measure in Study 2 assessed MDD, a multifaceted clinical syndrome. It may be that propensities and/or intolerances for guilt and shame are relevant to some symptoms of depression but not others. In addition, future studies on depression and self-conscious emotions would benefit from examining rumination, which like worry is a form of perseverative thinking. As a past-oriented perseveration on existing (i.e., now unavoidable) unpleasant outcomes, rumination may be less influenced by shame aversion than is worry. On the other hand, both forms of perseveration may themselves be triggers for shame and thus be associated with greater shame-proneness. As it has been suggested (e.g., Wells & Matthews, 1994) that worry and rumination contribute similarly to psychological problems via metacognitive beliefs, our understanding of the relevance of shame to perseverative thinking may be improved by future research that draws more heavily on Wells’ (1995) Metacognitive Theory and additionally considers the role of metacognition. The present findings also have potential treatment implications for worry/GAD, especially if future studies replicate our findings. On the one hand, and though it remains an open question, worrying may help stave off experiences of shame even if feared outcomes come true, as individuals may believe they did all that they could to prevent or prepare for that outcome. On the other hand, elevations in shame aversion may paradoxically motivate engagement in behaviours that ultimately increase both worry and shame alike, such as procrastination (e.g., Fee & Tangney, 2000; St€ ober & Joormann, 2001). This would contribute to the maintenance of worry, as well as the distress and impairment it can engender. Indeed, our results are broadly consistent with treatment
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approaches for GAD that involve targeting emotional awareness and emotion regulation (see e.g., Treanor, Erisman, Salters-Pedneault, Roemer, & Orsillo, 2011). However, the present findings suggest there may be something to be gained by including a specific focus on being aware of and coping adaptively with shame, in particular. Overall, although no one is immune to shame, individuals who can tolerate shame to regulate it effectively may be less inclined to use worry as a maladaptive means of cognitively avoiding possible future shame or to engage in behaviours that may consequently increase the frequency or intensity of shame. Thus, further expanding our understanding of shame in worry and GAD, as well as whether shame can be effectively addressed with current treatments, is an important goal for future research.
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Sanderson, W. C., Beck, A. T., & Beck, J. (1990). Syndrome comorbidity in patients with major depression or dysthymia: Prevalence and temporal relationships. American Journal of Psychiatry, 147, 1025–1028. Schoenleber, M., & Berenbaum, H. (2010). Shame aversion and shame-proneness in Cluster C personality disorders. Journal of Abnormal Psychology, 119, 197–205. doi:10.1037/a0017982 Schoenleber, M., & Berenbaum, H. (2012). Aversion and proneness to shame in self- and informant-reported personality disorder symptoms. Personality Disorders: Theory, Research, & Treatment, 3, 294–304. doi:10.1037/a0025654 Schoenleber, M., Berenbaum, H., & Motl, R. (2014). Shame-related functions of and motivations for self-injurious behavior. Personality Disorder: Theory, Research, & Treatment, 5, 204–211. doi:10.1037/per0000035 Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86, 420–428. doi:10.1037/0033-2909.86.2.420 St€ ober, J., & Joormann, J. (2001). Worry, procrastination, and perfectionism: Differentiating amount of worry, pathological worry, anxiety, and depression. Cognitive Therapy and Research, 25, 49–60. doi:10.1016/S0191-8869(00)00163-X Tangney, J. P. (1995). Shame and guilt in interpersonal relationships. In J. P. Tangney & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 114–139). New York, NY: Guilford. Tangney, J. P., & Dearing, R. L. (2002). Shame and guilt. New York, NY: Guilford Press. Tangney, J. P., Dearing, R. L., Wagner, P. E., & Gramzow, R. (2000). The Test of Self-Conscious Affect-3 (TOSCA-3). Fairfax, VA: George Mason University. Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). What’s moral about the self-conscious emotions? In J. L. Tracy, R. W. Robins & J. P. Tangney (Eds.), The self-conscious emotions: Theory and research (pp. 21–37). New York, NY: Guilford. Tangney, J. P., Wagner, P. E., Fletcher, C., & Gramzow, R. (1992). Shamed into anger? The relation of shame and guilt to anger and self-reported aggression. Journal of Personality and Social Psychology, 62, 669–675. doi:10.1037/0022-3514.62.4.669 Tangney, J. P., Wagner, P. E., & Gramzow, R. (1992). Proneness to shame, proneness to guilt, and psychopathology.JournalofAbnormalPsychology,101,469–478.doi:10.1037/0021-843X.101.3.469 Treanor, M., Erisman, S. M., Salters-Pedneault, K., Roemer, L., & Orsillo, S. M. (2011). Acceptance-based behavioral therapy for GAD: Effects on outcomes from three theoretical models. Depression and Anxiety, 28, 127–136. doi:10.1002/da.20766 Turk, C. L., Heimberg, R. G., Luterek, J. A., Mennin, D. S., & Fresco, D. M. (2005). Emotion dysregulation in generalized anxiety disorder: A comparison with social anxiety disorder. Cognitive Therapy and Research, 5, 89–105. doi:10.1007/s10608-005-1651-1 Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134, 163–206.doi:10.1037/0033-2909.134.2.163 Watson, D., & Clark, L. A. (1991). The mood and anxiety symptom questionnaire. Unpublished manuscript. University of Iowa. Watson, D., Weber, K., Assenheimer, J. M., Clark, L., Strauss, M. E., & McCormick, R. A. (1995). Testing a tripartite model: I. Evaluating the convergent and discriminant validity of anxiety and depression symptom scales. Journal of Abnormal Psychology, 104, 3–14. doi:10.1037/ 0021-843X.104.1.3 Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320. doi:10.1017/S1352465800015897 Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Hove, UK: Erlbaum. Williams, K. E., Chambless, D. L., & Ahrens, A. (1997). Are emotions frightening? An extension of the fear or fear construct. Behaviour Research and Therapy, 35, 239–248. doi:10.1016/S0005-7967 (96)00098-8 Received 2 September 2013; revised version received 17 January 2014
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Self-conscious emotions in worry and generalized anxiety disorder Michelle Schoenleber*, Philip I. Chow and Howard Berenbaum University of Illinois at Urbana-Champaign, Champaign, Illinois, USA Objectives. Current theories regarding worry and generalized anxiety disorder (GAD) highlight the potential avoidance functions of worry, and it has been suggested that worry functions to avoid self-conscious emotions in particular. Therefore, the present study examined the roles of proneness and aversion to self-conscious emotions in worry and GAD. Design. Cross-sectional data from two samples were collected: (1) a sample of 726 undergraduates, and (2) a selected sample of 51 community members, 37.3% of whom met DSM-IV criteria for GAD. Zero-order correlations and hierarchical multiple regression analyses were used to examine associations of self-conscious emotion constructs to worry and GAD. Method. Proneness to guilt and shame (propensities for experiencing guilt and shame, respectively) were assessed via the Test of Self-Conscious Affect-3. Aversion to guilt and shame (perceptions of guilt and shame, respectively, as especially painful, undesirable emotions) were assessed using the Guilt Aversion Assessment and Shame-Aversive Reactions Questionnaire, respectively. Worry was assessed using the Penn State Worry Questionnaire, and GAD was assessed via the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Results. Correlations indicated positive associations between self-conscious emotion constructs and worry/GAD. However, in the selected community sample, regression analyses indicated that only shame aversion was positively associated with worry/GAD, over and above all other self-conscious emotion constructs and depression. Conclusions. Results suggest a prominent role for an intolerance for shame in worry and GAD, which is broadly consistent with psychological models of worry. Future directions for research and clinical implications are discussed.
Practitioner points
Positive clinical implications Evidence supporting the theorized importance of self-conscious emotions in worry and GAD. Specifically highlights the need to address intolerance for shame in treatment.
Limitations Small sample size in Study 2. Use of cross-sectional data.
*Correspondence should be addressed to Michelle Schoenleber, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA (email: [email protected]). DOI:10.1111/bjc.12047
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Most psychological models of worry and generalized anxiety disorder (GAD) focus on the probable avoidance functions of worry. The Cognitive Avoidance Model (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004) asserts that worry, a core characteristic of GAD (American Psychiatric Association [APA], 2000, 2013), is used to prevent and/or prepare for unpleasant events, as well as to dampen the somatic arousal engendered by feared contexts. Similarly, others have suggested that worry serves a broad experiential avoidance function, motivated by discomfort with unpleasant internal experiences in general (e.g., thoughts, feelings, sensations; see Roemer, Salters, Raffa, & Orsillo, 2005). Consistent with these models, individuals with elevated GAD symptomatology often endorse positive beliefs about worry (e.g., Borkovec & Roemer, 1995), and experiential avoidance is positively associated with worry/GAD (e.g., Roemer et al., 2005). However, worry is itself associated with unpleasant emotional experience (e.g., trait negative affect, general distress; Watkins, 2008; Lee, Orsillo, Roemer, & Allen, 2010), suggesting that worry may not function to avoid distress altogether. With this in mind, Newman and Llera (2011) extended these existing theories in the Contrast Avoidance Model. Reviewing the findings regarding worry and negative emotionality (e.g., reactivity to unpleasant emotional stimuli), they posited that worry sustains distress so that individuals can avoid experiencing a shift from a relatively positive emotional state to a more negative emotional state. Indeed, individuals with elevated GAD symptomatology report feeling better able to cope with unpleasant emotional stimuli if they had previously been worrying, but less able to cope if they had been relaxing (Llera & Newman, 2010). Furthermore, individuals with elevated worry/GAD symptomatology report using worry to distract themselves from even more distressing topics (Borkovec & Roemer, 1995; Freeston, Rheaume, Letarte, Dugas, & Ladouceur, 1994). Drawing on all of these models, the present investigation examined the associations between worry/GAD and emotion-related personality traits that may motivate the use of worry as an avoidance strategy. First, trait propensities to experience certain unpleasant emotions readily across situations (i.e., proneness for certain emotions) may increase the use of worry; emotions that pose the greatest threat of elicitation also pose the greatest threat of creating increases in distress and/or a negative emotional contrast. Second, trait tendencies to perceive of certain emotions as especially painful and undesirable (i.e., aversion to certain emotions) may increase the use of worry; emotions that are particularly difficult to tolerate are those that likely increase the use of avoidance strategies in general, including worry. This study focused on the role of traits related to two unpleasant self-conscious emotions – guilt and shame – in worry and GAD. The capacity for self-conscious emotions develops around age two, as children acquire self-awareness and the ability to evaluate self-representations (e.g., Lewis, Sullivan, Stanger, & Weiss, 1989), and are thus considered cognitively complex emotions. Furthermore, these emotions are sometimes thought of as ‘social’ or ‘moral’ emotions, as they can be elicited by failing to live up to personal standards or shared social conventions and may motivate socially appropriate or moral behaviour (see Tangney, Stuewig, & Mashek, 2007, for review). However, guilt and shame are far from synonymous emotions. Drawing on the definitions provided in Lewis’ (1971) seminal work, guilt is defined as an emotion elicited when people negatively evaluate what they do and that often leads to efforts to apologize or make reparation; by comparison, shame is defined as an emotion elicited when people negatively evaluate who they are and that motivates social avoidance behaviour. There are several theoretical reasons to expect that self-conscious emotions, in particular, may be associated with worry and GAD. To begin with, it has previously been
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suggested that self-conscious emotions are prominent among those that individuals are trying to avoid by worrying (Freeston et al., 1994; Gosselin et al., 2003). Indeed, if individuals believe that worry is helping them prepare for or prevent feared outcomes, then they may feel less guilty or ashamed when the outcome does come true. In other words, the feared outcome may have happened, but at least they tried to stop it (so they may believe). Or, from a contrast avoidance perspective, at least they had readied themselves for the distress they knew the feared outcome would cause. Moreover, GAD has been theorized and also found to be associated with interpersonal problems (e.g., Borkovec, Newman, Pincus, & Lytle, 2002), and as mentioned above, self-conscious emotions are often social in nature (see Tangney & Dearing, 2002). Additionally, research also supports the potential relevance of self-conscious emotion to worry, albeit somewhat indirectly. For example, elevated worry is associated with diminished self-esteem, lower perceived competence, and higher personal inadequacy/incompetence (Berenbaum, Thompson, & Bredemeier, 2007; Breitholtz, Johansson, & Ost, 1999; Davey & Levy, 1999; Meyer, Miller, Metzger, & Borkovec, 1990), all of which may elicit guilt and/or shame. In fact, drawing on that research, it has been proposed elsewhere that diminished perceptions of competence – which may elicit these self-conscious emotions – play an important role in the genesis of worry (see Berenbaum, 2010). To date, only one study has examined the importance of propensities for self-conscious emotion to worry, and none have considered their importance to GAD symptoms. Fergus and colleagues (Fergus, Valentiner, McGrath, & Jencius, 2010) examined guilt- and shame-proneness in a sample of 127 outpatients (28 of whom had a diagnosis of GAD) who received intensive treatment at an anxiety disorders clinic. Results indicated that self-reported worry on the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990) was positively associated with shame-proneness but was not associated with guilt-proneness. Furthermore, greater changes in worry from pre- to post-treatment were associated with larger changes in shame-proneness. Similarly, only one previous study has considered the importance of constructs similar to aversions to self-conscious emotions to GAD symptomatology. Llera and Newman (2010) found that individuals in a GAD analogue group (based on self-reported GAD symptoms on the Generalized Anxiety Disorder Questionnaire-IV; Newman et al., 2002) were more likely to perceive of ‘guilt’ as a threatening emotion than were individuals in a non-anxious control group. However, as the terms ‘guilt’ and ‘shame’ are often used interchangeably in lay language, it remains an open question whether either or both of these unpleasant self-conscious emotions is perceived to be threatening. The present study is therefore additionally the first to consider both aversions to and propensities for self-conscious emotions in relation to worry/GAD at the same time. Importantly, guilt and shame are often differentially associated with psychological problems. Although guilt is often assumed to promote psychological problems because it is an unpleasant emotion and sometimes demonstrates significant positive bivariate correlations with measures of psychological distress (e.g., Tangney, Wagner, & Gramzow, 1992), research has consistently shown that shame-free guilt tends to be associated with prosocial behaviours and good interpersonal functioning (e.g., de Hooge, Zeelenberg, & Breugelmans, 2007; Leith & Baumeister, 1998; Tangney, 1995); in other words, the relationships between guilt and psychological problems become non-significant after taking into account the association between guilt and shame. The same is not true of shame, however. Shame is positively associated with a wide variety of psychological problems, even after taking guilt into account (e.g., Tangney et al., 1992). Indeed, the differential action tendencies associated with guilt and shame – approach versus
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avoidance, respectively – suggest that shame, but not guilt, might be particularly important to worry. Thus, although theories and research regarding worry generally do not differentiate between guilt and shame (see Fergus et al., 2010, as an exception), the self-conscious emotion literature suggests that only shame will be positively associated with worry/GAD. The present investigation therefore examined propensities and intolerances for each of these emotions separately. Additionally, several studies have found that worry/GAD is associated with greater tendencies toward depression. Indeed, there are high rates of comorbidity between GAD and major depressive disorder (MDD; e.g., Brown & Barlow, 1992; Sanderson, Beck, & Beck, 1990), and elevations in worry and GAD symptomatology are positively associated with depression (e.g., Olatunji, Broman-Fulks, Bergman, Green, & Zlomke, 2010). Moreover, depression is itself associated with unpleasant self-conscious emotion (see e.g., Kim, Thibodeau, & Jorgensen, 2011) and includes feelings of guilt and worthlessness (suggestive of shame) among its criteria (APA, 2000). Thus, it is important that research on the roles of self-conscious emotion in worry/GAD take depressive symptomatology into consideration as well. In summary, the present investigation examined the relevance of proneness for guilt and shame, as well as aversion to guilt and shame, to worry and GAD symptoms. We hypothesized that elevations in worry and GAD symptoms would be associated with higher levels of both shame-proneness and shame aversion. However, we expected that worry and GAD would show no association with guilt-proneness or guilt aversion. To consider the specificity of the associations between worry/GAD and these self-conscious emotion constructs, we additionally explored the associations between depression and propensities and intolerances for self-conscious emotions. As the present research was the first to consider the relevance of guilt and shame aversions to any form of anxiety disorder, we began by testing these hypotheses in a large undergraduate sample. Subsequently, we sought to replicate and extend the findings of our initial study by examining proneness and aversion to self-conscious emotions in a selected community sample.
STUDY 1 Method Participants Participants in Study 1 were 726 undergraduates (69.3% female) with a mean age of 19.6 years (SD = 1.3). The majority of this sample (65.9%) described themselves as White/Non-Hispanic, followed by 15.0% Asian American, 6.5% Hispanic/Latino(a), 4.5% African American, 3.3% Multiracial, and with 4.8% describing themselves as ‘Other.’ All participants completed a voluntary informed consent at the start of the session and received course credit for participation. Measures Shame- and guilt-proneness We used the guilt and shame items from the Test of Self-Conscious Affect-3 (Tangney, Dearing, Wagner, & Gramzow, 2000) to assess participants’ tendencies to experience shame and guilt, respectively, readily and often. The TOSCA-3 presents participants with 16 brief scenarios that could potentially elicit guilt- and/or shame-related responses (e.g.,
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‘While out with a group of friends, you make fun of a friend who’s not there’). Using a 5-point Likert scale, participants indicate the extent to which they would experience a possible guilt response (‘You would apologize and talk about the person’s good points’), as well as a possible shame response (‘You would feel small...like a rat’). The TOSCA-3 guilt- and shame proneness scales have been shown to be valid and reliable (e.g., Tangney, Wagner, Fletcher, & Gramzow, 1992). Cronbach’s alpha was .70 for the guilt-proneness scale and was .81 for the shame-proneness scale. Guilt aversion The Guilt Aversion Assessment (GuAvA) was used to measure individuals’ perceptions of guilt as particularly distressing and unwanted (Schoenleber & Berenbaum, 2012). Participants indicated their agreement with each of 16 items (e.g., ‘I hate feeling accountable after I’ve done something bad’) on a 7-point scale. Guilt aversion shows expected positive associations with shame aversion and with guilt- and shame-proneness, both in previous work (Manjrekar, Schoenleber, & Mu, 2013; Schoenleber & Berenbaum, 2012; Schoenleber et al., 2014) and in the present sample, as can be seen in Table 1. The GuAvA has also shown expected relationships to trait affect, experiential avoidance, and psychological problems, as well as having good internal consistency (see Manjrekar et al., 2013; Schoenleber & Berenbaum, 2012; Schoenleber et al., 2014). Cronbach’s alpha for the GuAvA was .87 in this study. Shame aversion Participants completed the Shame-Aversive Reactions Questionnaire (ShARQ; Schoenleber & Berenbaum, 2010), which measures the degree to which shame is perceived to be an especially painful and undesirable emotion. Using a 1–7 scale, participants indicate their agreement with each of 14 statements (e.g., ‘Feeling inadequate troubles me more than anything else’). The ShARQ has displayed good convergent validity and internal consistency in previous research (see Schoenleber & Berenbaum, 2010, 2012; Schoenleber, Berenbaum, & Motl, 2014). Internal consistency for the ShARQ was also good in the present sample (a = .83).
Worry The PSWQ (Meyer et al., 1990) was used to assess the tendency to worry in both samples. On the PSWQ, participants rated 16 statements (e.g., ‘My worries overwhelm me’) with regard to how typical each is of them on a 1 to 5 scale. Previous studies indicate that the PSWQ has good convergent validity and test–retest reliability (e.g., Meyer et al., 1990). In the present study, Cronbach’s alpha was .94. Anhedonic depression Participants completed the anhedonic depression subscale of the Mood and Anxiety Symptoms Questionnaire (MASQ; Watson & Clark, 1991). Twenty-one items rated on a 5-point Likert scale are used to assess the degree to which individuals experience depression-related deficits in pleasure; the item assessing suicidal ideation was not included. The MASQ anhedonic depression subscale displays good validity and reliability (Watson et al., 1995), and internal consistency was also good in the present study (a = .93).
.35** –
– .38** .19** .25** –
–
Guilt Aversion
.25** .01
Guilt-Proneness
Note. M, Mean; SD, Standard Deviation; Min, Minimum; Max, Maximum. **p < .01.
Worry Anhedonic Depression Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
Anhedonic Depression
Worry
.33** .41** –
.42** .31**
Shame-Proneness
.04 .36** .41** –
.44** .43**
Shame Aversion
Table 1. Descriptive statistics for and relationships among worry, anhedonic depression, and self-conscious emotions for Study 1
63.5 72.4 45.4 51.4
49.7 48.2
M
6.9 15.4 9.7 12.4
13.7 13.7
SD
38 21 17 19
16 21
Min
80 110 73 87
80 96
Max
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Results To begin with, we explored the extent to which our undergraduate sample evidenced potentially important levels of worry and anhedonic depression. A total of 110 participants (15.2%) had scores on the PSWQ of at least 65, which was the mean score found for a clinical sample of individuals with GAD (SD = 10; see Meyer et al., 1990); an additional 148 participants (20.4%) were within 1 SD below the clinical sample’s mean score. A total of 81 participants (11.2%) had anhedonic depression scores on the MASQ of at least 65.5, which was the mean score found for a patient sample (SD = 14.8; see Watson et al., 1995); an additional 187 participants (25.8%) were within 1 SD below the patient sample’s mean score. Thus, the present undergraduate sample included a wide range of worry and anhedonic depression severity, including a substantial number of participants evidencing concerns similar to those of generally more severe samples. Next, we investigated whether guilt and/or shame constructs were associated with worry. Descriptive statistics for and relationships among worry, anhedonic depression, and self-conscious emotion constructs are presented in Table 1. As shown in Table 1, worry was positively associated with anhedonic depression and all self-conscious emotion constructs. Following previous research (e.g., Fergus et al., 2010), we next considered the incremental predictive utility of guilt and shame constructs, over and above one another as well as anhedonic depression. Specifically, we ran a hierarchical multiple regression analysis with anhedonic depression entered in Step 1 and all of the self-conscious emotion constructs entered simultaneously in Step 2.1 As shown in the left portion of Table 2, in Step 1 higher scores for anhedonic depression were associated with greater worry. In Step 2, all self-conscious emotion constructs were also positively associated with worry. Interestingly, shame aversion exhibited the strongest association with worry. For the purpose of comparison, we ran a regression analysis similar to that above, but with worry in Step 1 and with anhedonic depression as the outcome variable, as shown in Table 2. As with worry, in Step 2 elevations in anhedonic depression were associated with higher shame-proneness and shame aversion. However, unlike worry, anhedonic depression was negatively associated with guilt-proneness and not associated with guilt aversion.2
STUDY 2 Method Participants Fifty-one individuals were recruited from a small Midwestern city to participate in a larger research project, one goal of which was to examine the associations between self-conscious emotions and worry/GAD.3 Specifically, individuals were recruited via 1 All of the hierarchical multiple regression analyses presented in this article were also run with an additional fourth step in which we entered the shame-proneness 9 shame aversion and the guilt-proneness 9 guilt aversion interaction terms. None of the interactions in any of the regression analyses involving worry or GAD symptoms were significant. 2 In addition, there was a significant shame-proneness x shame aversion interaction (b = .07, p < .05). Simple slopes analyses indicated that although there was a significant positive association between shame-proneness and anhedonic depression when shame aversion was high (b = .21, p < .01), this association fell just short of statistical significance when shame aversion was low (b = .10, p = .052). 3 No other inclusion/exclusion criteria were employed at the time of recruitment; however, data from two additional individuals were not included in the present investigation due to the presence of symptoms of psychosis and/or mania.
Note. *p < .05; **p < .01.
Step 1 Anhedonic Depression/MDD Symptoms or GAD Symptoms Step 2 Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
.15** .17** .16** .23**
.35**
b
Worry
.21**
.12**
DR2
.12** .03 .15** .30**
.35**
b
.12**
.12**
DR2
Anhedonic Depression
Study 1 (N = 726)
.03 .07 .08 .59**
.26
b
Worry
.45**
.07
DR2
.14 .23 .04 .40*
.30*
b
.28**
.09*
DR2
GAD Symptoms
Study 2 (N = 51)
Table 2. Summary of hierarchical multiple regression analyses for worry, generalized anxiety disorder, and major depressive disorder
.00 .22 .46** .23
.30*
b
.09
.09*
DR2
MDD Symptoms
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public advertisements seeking individuals who worry frequently. Participants were 20– 61 years old (M = 36.9; SD = 12.8) and 66.7% were female. Consistent with the population characteristics of the local community, the majority of participants (72.5%) were White/Non-Hispanic, followed by 9.8% African American, 7.8% Asian American, 5.9% Multiracial, and 3.9% describing themselves as ‘Other.’ All participants completed a voluntary informed consent at the start of the session and received monetary compensation for their participation. Measures Self-conscious emotions and worry As with Study 1, participants in Study 2 completed the following: (1) TOSCA-3 (guilt-proneness a = .77; shame-proneness a = .81), (2) GuAvA (a = .87), (3) ShARQ (a = .88), and (4) PSWQ (a = .94). Anxiety and mood disorders Additionally, all participants in Study 2 were interviewed using the anxiety and mood disorder modules of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002) to assess symptoms of Axis I anxiety and mood disorders. Given the a priori hypotheses for this study, we were interested primarily in GAD, as well as in MDD as a covariate and indicator of general distress. All interviews were conducted by the first and second authors, each of whom were advanced graduate students with at least 2 years of training in the use of the SCID-I for clinical and research purposes. Each criterion was rated on a scale from 0 to 2 with 0 indicating the absence of a given symptom, 1 indicating subthreshold presence of the symptom, and 2 indicating that the diagnostic criterion was met. In addition to determining whether each participant met criteria for anxiety or mood disorders, we also calculated a weighted symptom count for GAD and lifetime MDD. All interviews were audiotaped, and 15 were randomly selected for secondary ratings; inter-rater reliability was measured using the intraclass correlation following Shrout and Fleiss (1979), treating raters as random effects and the individual rater as the unit of reliability. The intraclass correlation was .98 for GAD and .99 for MDD.
Results First, we examined the extent to which this selected, community-based sample evidenced clinically significant levels of GAD and other forms of psychopathology. Descriptive statistics are presented in Table 3. Consistent with our recruitment advertisements seeking individuals who worry, 30 participants met at least one diagnostic criterion of GAD, with 19 participants (37.3%) displaying sufficient symptoms to meet criteria for a diagnosis of that disorder. Thus, the present sample contained a relatively wide range of GAD symptom severity, with a significant portion of the sample reporting clinically important GAD symptoms. Lifetime symptoms of MDD were also common. Although only two participants were currently experiencing a major depressive episode, 24 (47.1%) had experienced at least one episode during their lifetime. Of these 24 participants, 10 met criteria for GAD as well. Many participants met criteria for other anxiety disorders: 21.6% for social phobia, 7.8% for obsessive-compulsive disorder, and 5.9% for panic disorder, specific phobia, and/or posttraumatic stress disorder.
–
.79** –
GAD Symptoms .28* .25 –
MDD Symptoms .09 .20 .24* –
Guilt-Proneness
Note. M, Mean; SD, Standard Deviation; Min, Minimum; Max, Maximum. *p < .05; **p < .01.
Worry GAD Symptoms MDD Symptoms Guilt-Proneness Guilt Aversion Shame-Proneness Shame Aversion
Worry .34** .41** .07 .35** –
Guilt Aversion .53** .45** .33* .41** .60** –
Shame-Proneness .68** .49** .13 .06 .37** .66** –
Shame Aversion
54.7 7.0 7.4 66.9 70.6 49.2 58.7
M
Table 3. Descriptive statistics for and relationships among worry, GAD and MDD symptoms, and self-conscious emotions for Study 2
14.5 5.8 7.2 7.5 16.5 11.0 14.5
SD
25 0 0 42 33 21 21
Min
75 16 18 77 106 69 86
Max
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Next, we investigated whether guilt and/or shame constructs were associated with worry and/or GAD symptoms. As shown in Table 3, PSWQ worry and SCID-I weighted GAD symptom counts were both positively associated with shame-proneness, shame aversion, and guilt aversion. However, guilt-proneness was not associated with either worry or GAD symptoms. Not surprisingly, individuals with GAD also reported significantly greater shame-proneness, shame aversion, and guilt aversion than did individuals who did not meet diagnostic criteria for GAD, ts(49) = 3.18, 3.56, and 2.72, all ps ≤ .01, respectively. Next, as in Study 1, we examined the incremental predictive utility of all self-conscious emotion constructs over and above one another, as well as over and above MDD. A pair of hierarchical multiple regression analyses were run, entering MDD weighted symptom count in Step 1 and all self-conscious emotion constructs in Step 2. As shown in the right portion of Table 2, in Step 1 of these analyses, although the association between MDD and PSWQ worry fell short of significance (b = .26, p = .064), the association between MDD and SCID-I GAD was statistically significant. In Step 2 of these analyses, and consistent with the fact that it exhibited the strongest relationship to worry in Study 1, greater shame aversion was associated with elevations in PSWQ worry (b = .59, p < .01) and greater SCID-I GAD (b = .40, p < .05); none of the remaining self-conscious emotion constructs were significantly associated with these outcomes. Finally, we conducted another regression analysis similar to that above, but using SCID-I GAD symptom scores in Step 1 and MDD symptoms as the outcome variable, as shown in Table 2. The results in Step 2 of this analysis differed from those for GAD symptoms in multiple ways. First, although statistically non-significant, the association between MDD symptoms and guilt aversion was negative, whereas that between GAD symptoms and guilt aversion was of equal magnitude but positive. Second, unlike GAD symptoms, the association between MDD symptoms and shame aversion was both negative and statistically non-significant. Third, the association between MDD and shame-proneness was statistically significant, with elevations in MDD symptoms being associated with higher levels of shame-proneness.
GENERAL DISCUSSION Results were generally consistent with our predictions, overall supporting a role for self-conscious emotions in worry and GAD symptoms. First, in Study 1 all self-conscious emotion constructs were positively associated with worry, over and above anhedonic depression. Second, using a selected community sample in Study 2, shame aversion emerged as the only self-conscious emotion construct significantly associated with worry and GAD symptoms after also taking MDD symptoms into account. Thus, our findings indicate that greater intolerance for shame, in particular, may be especially relevant to elevations in worry and GAD symptoms. Additionally, that shame aversion’s associations to worry and GAD remained significant even after taking levels of depressive symptomatology into account suggests that the relevance of shame aversion to worry/GAD is not attributable to other Axis I disorders related to shame or to the similarities between depression and anxiety (e.g., Mineka, Watson, & Clark, 1998). Importantly, our findings are consistent with existing models of worry/GAD that focus on the avoidance functions of worry (e.g., Borkovec et al., 2004; Newman & Llera, 2011; Roemer et al., 2005), as well as with previous suggestions that self-conscious emotions, in particular, are the target of such avoidance (e.g., Freeston et al., 1994; Gosselin et al., 2003). Indeed, it is reasonable to assume that aversions to emotion motivate behavioural
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attempts (e.g., worrying) to reduce the likelihood of those emotions. Our results suggest that an aversion to shame, specifically, may motivate individuals to use worry in order to avoid that particular emotional state. Admittedly, however, the present study cannot directly address whether shame aversion motivates worry or whether worry actually down-regulates shame or shame-related emotional contrasts. It remains an open question whether worry is at all effective as a shame regulation strategy, one that we hope will be considered in future investigations using experimental designs. As mentioned above, ours is the first study to examine guilt aversion and shame aversion, separately and specifically, in worry and GAD. Although one previous study (Llera & Newman, 2010) found that individuals in a GAD analogue group reported higher perceptions of ‘guilt’ as threatening than did a non-anxious control group, that study could not speak to the potentially differential importance of guilt and shame to worry/ GAD. Additionally, although likely related concepts, perceived threat is not necessarily synonymous with aversion. As such, the present study extends this past research, indicating that it is the tendency to perceive of shame, specifically, as painful and undesirable that is associated with higher levels of worry and GAD symptoms. Our results also extend those of the one existing study that examined proneness to self-conscious emotions in relation to worry (Fergus et al., 2010). Partial correlations in that study showed that shame-proneness was positively associated with worry after taking guilt-proneness into account, but the opposite was not true. Post-hoc analyses in our samples revealed a similar prominent importance for shame-proneness over guilt-proneness; partial correlations for our community sample replicated the findings of Fergus et al. (for worry and GAD, respectively: shame-proneness, rs = .56 and .42, ps < .001; guilt-proneness, rs = -.11 and .11, ps = n.s.). Similarly, in our undergraduate sample the partial correlation for shame-proneness (r = .37, p < .001) was significantly greater than the partial correlation for guilt-proneness (r = .13, p < .001; t(723) = 5.96, p < .001). Our data therefore support the assertion that shame-proneness is important in worry and GAD over and above guilt-proneness. However, a propensity for shame may not be as relevant to worry and GAD as is an aversion to that emotion. By comparison, shame-proneness continued to be positively associated with anhedonic depression in Study 1 and with MDD symptoms in Study 2 even after taking shame aversion into account. In fact, whereas shame aversion demonstrated an inconsistent relationship to depression across our two samples, greater propensities for shame were associated with elevations in depressive symptomatology among both undergraduates and community members. Thus, although they are often co-occurring problems, worry/GAD and depression may be distinguishable in part by their differential relationships to shame-related constructs. Our findings must be interpreted in light of the study’s limitations, which also highlight important directions for future research. First, both of our samples included individuals who reported significant concerns related to worry (15.2% of undergraduates endorsing levels of worry at or above the mean of a clinical sample; 37.3% of community members endorsing symptoms of GAD sufficient for diagnosis). However, future studies would benefit from the use of clinical samples that may include an even greater number of individuals experiencing more serious distress and impairment as a result of frequent, under-controlled worry. A second limitation of the present research was that our studies did not include broader measures of emotional intolerance (e.g., experiential avoidance) and/or measures of aversion to other specific emotions. For example, existing research indicates that fears of depression are positively associated with worry/GAD (Roemer et al., 2005; Turk,
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Heimberg, Luterek, Mennin, & Fresco, 2005) and distinguish between individuals in a GAD clinical sample versus a non-clinical comparison group (Roemer et al., 2005). Perceptions of sadness as threatening also distinguish between individuals high versus low on self-report measures of GAD symptoms (Llera & Newman, 2010). Given this research, it will be important for future studies to consider whether shame aversion remains an important correlate of worry/GAD over and above an aversion to depression. Furthermore, some models of worry/GAD suggest that a broader form of intolerance – intolerance of uncertainty – is central in perpetuating the use of worry as a cognitive avoidance strategy (e.g., Dugas, Gagnon, Ladouceur, & Freeston, 1998). It remains to be seen whether intolerances for specific emotional experiences are relevant to worry/GAD above and beyond discomfort with ambiguous situations more generally. Although our results indicate that shame aversion is relevant to worry/GAD over and above a number of other potential explanatory constructs, inclusion of measures such as the Affect Control Scale (Williams, Chambless, & Ahrens, 1997) and Intolerance of Uncertainty scale (Buhr & Dugas, 2002) would provide a more stringent test of our hypotheses. A third limitation is that the present study only considered proneness and aversion to guilt and shame in worry/GAD and anhedonic depression/MDD; however, it is possible that some or all of these constructs are also relevant for understanding other psychological problems. In particular, it would be useful for future studies to consider the relative roles of proneness and aversion to other forms of psychopathology, such as social phobia and posttraumatic stress disorder, both of which are theoretically (e.g., Clark & Wells, 1995; Resick & Schnicke, 1992) and empirically (e.g., Fergus et al., 2010; Leskela, Dieperink, & Thuras, 2002) associated with self-conscious emotions. Further research on proneness and aversion to self-conscious emotions in depression is also warranted, especially given the inconsistency in our findings regarding shame aversion. Our findings may be partially attributable to measure-related differences across our two studies; the measure in Study 1 focused on one particular feature of depression – loss of interest/diminished capacity for pleasure – whereas the measure in Study 2 assessed MDD, a multifaceted clinical syndrome. It may be that propensities and/or intolerances for guilt and shame are relevant to some symptoms of depression but not others. In addition, future studies on depression and self-conscious emotions would benefit from examining rumination, which like worry is a form of perseverative thinking. As a past-oriented perseveration on existing (i.e., now unavoidable) unpleasant outcomes, rumination may be less influenced by shame aversion than is worry. On the other hand, both forms of perseveration may themselves be triggers for shame and thus be associated with greater shame-proneness. As it has been suggested (e.g., Wells & Matthews, 1994) that worry and rumination contribute similarly to psychological problems via metacognitive beliefs, our understanding of the relevance of shame to perseverative thinking may be improved by future research that draws more heavily on Wells’ (1995) Metacognitive Theory and additionally considers the role of metacognition. The present findings also have potential treatment implications for worry/GAD, especially if future studies replicate our findings. On the one hand, and though it remains an open question, worrying may help stave off experiences of shame even if feared outcomes come true, as individuals may believe they did all that they could to prevent or prepare for that outcome. On the other hand, elevations in shame aversion may paradoxically motivate engagement in behaviours that ultimately increase both worry and shame alike, such as procrastination (e.g., Fee & Tangney, 2000; St€ ober & Joormann, 2001). This would contribute to the maintenance of worry, as well as the distress and impairment it can engender. Indeed, our results are broadly consistent with treatment
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approaches for GAD that involve targeting emotional awareness and emotion regulation (see e.g., Treanor, Erisman, Salters-Pedneault, Roemer, & Orsillo, 2011). However, the present findings suggest there may be something to be gained by including a specific focus on being aware of and coping adaptively with shame, in particular. Overall, although no one is immune to shame, individuals who can tolerate shame to regulate it effectively may be less inclined to use worry as a maladaptive means of cognitively avoiding possible future shame or to engage in behaviours that may consequently increase the frequency or intensity of shame. Thus, further expanding our understanding of shame in worry and GAD, as well as whether shame can be effectively addressed with current treatments, is an important goal for future research.
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