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Self compassion and shame-proneness in five different mental disorders: Comparison with healthy controls

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Background and objectives: The lack of self-compassion and shame-proneness may both be associated with a wide range of mental disorders. The aim of this study was to compare the levels of self-compassion and shame-proneness in samples of patients with anxiety disorders, depressive disorders, eating disorders, borderline personality disorder, alcohol-addiction and in healthy controls.
Methods: All five clinical groups and healthy controls were administered scales measuring self-compassion (SCS) and shame-proneness (TOSCA-3S). Differences in self-compassion and shame-proneness were analyzed and effect sizes were calculated.
Results: All five clinical groups were found to have significantly lower self-compassion and significantly higher shame-proneness than healthy controls. The magnitudes of difference in self-compassion and shame-proneness, between all clinical groups and healthy controls, were all large.
Discussion: We hypothesize, that the lack of self-compassion leads to increased shame-proneness, which causes various psychopathological symptoms. The lack of self-compassion may therefore be important underlying factor causing many different mental problems.
Conclusion: The lack of self-compassion and shame-proneness proved to be TRANSDIAGNOSTIC FACTORS in five different mental disorders. We assume, that clients suffering from all these disorders may benefit from treatments or particular interventions that facilitate the development of self-compassion or shame management.

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Self compassion and shame-proneness in five different mental disorders: Comparison with healthy controls

  1. 1. Self-compassion and shame-proneness in five different mental disorders: Comparison with healthy controls J. BENDA, P. KADLEČÍK, D. KOŘÍNEK, M. DVOŘÁKOVÁ, A. VYHNÁNEK, T. ZÍTKOVÁ ROOTS AND GIFTS OF INTEGRATIVE PSYCHOTHERAPY PRAHA, 12.-14. 10. 2018 1
  2. 2. Background 2
  3. 3. 3 ? Anxiety disorders Depressive disorders Eating disorders Borderline personality disorder Alcohol- addiction Transdiagnosticfactor
  4. 4. 4 shame Anxiety disorders Depressive disorders Eating disorders Borderline personality disorder Alcohol- addiction Transdiagnosticfactor
  5. 5. What is shame? 5  Shame is a self-conscious emotion associated with feelings of inadequacy, inferiority and worthlessness and with a desire to hide or conceal deficiencies.  It is a “social” or “moral” emotion that can be seen as resulting from the comparison of the self's action and experiences with the self's standards.  Shame-proneness is closely related to self-criticism.
  6. 6. Shame x guilt 6  The fundamental difference between shame and guilt concerns the role of the self.  Shame involves fairly global negative evaluations of the self (i.e., “I am not good enough, I am worthless”).  Guilt involves a more articulated condemnation of a specific behavior (i.e., „I did a bad thing”, see Tangney, Dearing, 2003).  Shame is therefore a much more problematic – maladaptive feeling (Cook, 2001; Greenberg, 2015).
  7. 7. Anxiety disorders  Anxiety results from unconscious catastrophic expectations  What is the worst that could happen?  (Fear of) condemnation, rejection, abandonment  = I am not enough, reprehensible (shame) 7
  8. 8. Depressive disorders  Depressive rumination includes negative self- narratives  „I am impossible, unacceptable.“  Hidden needs of acceptance, appreciation, forgiveness or coping with loss are not addressed  Feelings of inferiority, humiliation, loneliness (= shame) 8
  9. 9. Borderline personality disorder  3 maladaptive shame regulation strategies (Schoenleber, Berenbaum, 2012) 1. Prevention – e.g. the person avoids taking responsibility for tasks 2. Escape – e.g. self-promotion or social withdrawal 3. Agression – e.g. the person refocuses self-hate onto others and reacts accordingly  All these strategies = Indirect indicators of shame 9
  10. 10. Eating disorders  Body dissatisfaction, criticism of body image, self-esteem closely linked to body weight/shape  The effort to attain body perfection connected with hope for recognition, respect, admiration  Never good-enough(= shame) 10
  11. 11. Alcohol addiction  Alcohol provides immediate alleviation of negative affect (e.g. shame) 1. I feel bad (trigger) 2. I drink some alcohol (behavior) 3. I feel good (reward) = reinforcement  Substitution, true needs are not addressed (see Brewer, 2017) 11
  12. 12. What is the best protection (or antidote) against shame? SELF-COMPASSION 12
  13. 13. What is self-compassion? 13  According to Neff (2011b), self-compassion is a cognitive coping strategy that reflects an emotionally positive self-attitude in instances of perceived inadequacy, failure, or general suffering.  It is a counterpart of excessive self-criticism, self- rejection, „hardness of heart“ or “self-coldness” (see e.g. Boersma et al., 2015; Gilbert, 2010).
  14. 14. Self-compassion x self-pity 14  Self-pity – the position of victim, egocentrism, blaming others, self-rejection, the effort to control, manipulation, inability to mentally leave a painful situation, inferiority (it's not fair, why do bad things always happen to me?, everything is always my fault, I'm the poorest man on earth)  Self-compassion – accepting responsibility for oneself, accepting own imperfections, caring for oneself, ability to ask for help (to err is human, we are equal as humans, nobody is less than anybody else) (Paul, 2012; srov. Horniaková, 2015)
  15. 15. Self-compassion 15  Self-compassion inspired the development of many new psychotherapeutic procedures (see e.g. Desmond, 2016; Germer, 2009; Gilbert, 2010; Neff, 2011a).  Existing research confirms that: 1. self-compassion is most likely an important predictor of mental health and well-being (Neff, 2011a,b; Trompetter, 2016; Zessin, Dickhäuser, Garbade, 2015) a 2. the lack of self-compassion probably plays an important role in the etiopathogenesis of mental disorders (např. Hoge et al., 2013; Krieger et al., 2013; MacBeth, Gumley, 2012, aj.).
  16. 16. THE ATTITUDE TO EXP. PHENOMENAAND MENTAL HEALTH 1. acceptance 2. rejection (+ self-reference) flow of experiencing experienced phenomenon* mental health shame defense mechanisms depressions addictionsanxieties eating disorders psycho- somatics personality disorders and more… self-compassion (m. p. brahma vihára) emotion dys/regulation resistance (or self-coldness = tanhá) * perception, feeling, image, thought, mood… DOI: 10.13140/RG.2.1.5077.4167 16
  17. 17. Objectives 17  The aim of this study was to compare the levels of self- compassion and shame-proneness in samples of patients with 1. anxiety disorders 2. depressive disorders 3. eating disorders 4. borderline personality disorder (BPD) 5. alcohol addiction  and in healthy controls.
  18. 18. Methods 18
  19. 19. Anxiety sample (1) 19  INCLUSION CRITERIA: 1. Primary diagnosis of phobic anxiety disorders or other anxiety disorders (code F40-F41 according to ICD-10). 2. Age at least 18 years. 3. Rating of 10 or higher on the GAD-7 scale.  Participants were excluded if they had a comorbid diagnosis of any psychotic disorder, personality disorder, eating disorder, substance use disorder, organic brain disorder or mental retardation.
  20. 20. Depressed sample (2) 20  INCLUSION CRITERIA: 1. Primary diagnosis of major depressive disorder, single episode or major depressive disorder, recurrent (code F32-F33 according to ICD-10). 2. Age at least 18 years. 3. Rating of 10 or higher on the PHQ-9 scale.  Participants were excluded if they had a comorbid diagnosis of any psychotic disorder, personality disorder, eating disorder, substance use disorder, organic brain disorder or mental retardation.
  21. 21. BPD sample (3) 21  INCLUSION CRITERIA: 1. Primary diagnosis of emotionally unstable personality disorder (code F60.3 according to ICD-10). 2. Age at least 18 years.  Participants were excluded if they had a comorbid diagnosis of any psychotic disorder, eating disorder, substance use disorder, organic brain disorder or mental retardation.
  22. 22. Eating disorders sample (4) 22  INCLUSION CRITERIA: 1. Primary diagnosis of anorexia nervosa or bulimia nervosa (code F50.0 or F50.2 according to ICD-10). 2. Age at least 18 years. 3. Rating of 15 or higher on the three eating-disorder-specific subscales of the EDI scale. 4. Participants were excluded if they had a comorbid diagnosis of any psychotic disorder, personality disorder, substance use disorder, organic brain disorder or mental retardation.
  23. 23. Alcohol addiction sample (5) 23  INCLUSION CRITERIA: 1. Primary diagnosis of alcohol dependence (code F10.2 according to ICD- 10). 2. Age at least 18 years. 3. Rating of 20 or higher on the AUDIT scale.  Participants were excluded if they had a comorbid diagnosis of any psychotic disorder, eating disorder, organic brain disorder or mental retardation.
  24. 24. Healthy controls (0) 24  INCLUSION CRITERIA: 1. Age at least 18 years. 2. Rating ≤ 9 on the GAD-7 scale. 3. Rating ≤ 9 on the PHQ-9 scale.  Participants were excluded from this sample if they reported a history of any mental disorder or if they had a score ≥ 10 on the GAD-7 scale or the PHQ-9 scale.
  25. 25. Measures  Self-Compassion Scale (SCS-26-CZ, Neff, 2003; Czech version Benda, Reichová, 2016). Recently, critique has been raised regarding the factor structure of the SCS and the validity of the SCS total score (Benda, 2018; Muris, Otgaar, Pfattheicher, 2018). Therefore, only the Compassionate Self-responding subscale (13 items) was used in this study.  Test of Self-Conscious Affect-3S (TOSCA-3S, Tangney, Dearing, 2003; Czech version Dvořáková, 2013). Only the shame-proneness subscale was used in this study. 25
  26. 26. Measures  Generalized Anxiety Disorder-7 (GAD-7; Kroenke et al., 2010).  Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2010).  Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983). Only the eating-disorder-specific subscales (i.e. Drive for Thinness, Bulimia, Body Dissatisfaction) were used in this study.  The Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001). 26
  27. 27. Statistical analysis  Data was analyzed using the IBM SPSS Statistics software, Version 23.  Associations between study variables were analysed by calculating the Pearson’s correlation coefficients.  Differences in self-compassion and shame-proneness were analyzed using a two-way analysis of covariance (ANCOVA) with Bonferroni correction.  The effect sizes of the group comparisons were then calculated in terms of Cohen’s d. 27
  28. 28. Results 28
  29. 29. Demographic characteristics 29 N age (SD) males females anxiety sample 58 41.26 (13.02) 18 40 (69%) depressed sample 57 43.46 (13.68) 19 38 (66.7%) BPD sample 74 31.55 (8.58) 20 54 (73%) eating disorders sample 55 26.18 (9.10) 0 55 (100%) alcohol addiction sample 55 43.25 (11.64) 34 21 (38,2%) healthy controls 180 40.55 (8.43) 62 118 (65.6%)
  30. 30. Correlations between compassionate self- responding and shame-proneness anxiety sample -.38** depressed sample -.25** BPD sample -.46** eating disorders sample -.33* alcohol addiction sample -.01 healthy controls -.27** *p<0,05 **p<0,01 30
  31. 31. Boxplot of compassionate self-responding scores by group. 31
  32. 32. Boxplot of shame- proneness scores by group 32
  33. 33. Comparison of samples  The samples differed significantly in age (F(5, 473) = 29.747, p < .001) and gender (χ2(5, N = 479) = 90.201, p < .001).  To determine if there were significant group differences in study variables, two two-way ANCOVAs were conducted with the group and gender as fixed factors, age as a covariate and compassionate self-responding and shame-proneness as dependent variables. For pairwise comparisons post hoc t- tests with Bonferroni correction were then performed. 33
  34. 34. Means and standard deviations of study variables anxiety sample depressed sample BPD sample eating disorders alcohol addiction healthy controls F p η2 SCS-26-CZ-CS 33.78 (7.98) 34.58 (6.42) 28.00 (8.77) 28.36 (7.76) 34.22 (8.24) 43.11 (8.19) 40.659 < .001 .303 TOSCA-3S-S 36.52 (8.90) 34.25 (7.04) 39.32 (9.06) 39.85 (7.26) 32.95 (7.35) 28.26 (8.02) 28.749 < .001 .235 34 Post-hoc t-tests with Bonferroni correction indicated that all five clinical samples showed significantly lower compassionate self- responding and significantly higher shame-proneness than healthy controls (all p’s < .001).
  35. 35. Effect-sizes (d) for comparisons between clinical groups & healthy controls 35 SCS-26-CZ-CS TOSCA-3S-S anxiety sample vs. healthy controls 1.15 .98 depressed sample vs. healthy controls 1.16 .79 BPD sample vs. healthy controls 1.78 1.29 eating disorders sample vs. healthy controls 1.85 1.52 alcohol addiction sample vs. healthy controls 1.08 0.61
  36. 36. Conclusion 36
  37. 37. In the present study 1. All five clinical samples were found to have significantly lower self-compassion and significantly higher shame-proneness than healthy controls. Both the lack of self-compassion and shame-proneness thus proved to be transdiagnostic factors of these disorders. 2. The lack of self-compassion was essentially associated with shame in almost all samples (except alcohol addiction sample). 37
  38. 38. We hypothesize, that 1. the lack of self-compassion leads to the formation of shame whenever one experiences something that is perceived to be “wrong” in comparison with one’s self-ideal. And since shame is a painful feeling, various defense or coping mechanisms are then automatically activated, resulting in various psychopathological symptoms. Further study of these mechanisms may lead to a new understanding of the etiology of many mental disorders as well as a new understanding of the mechanisms of therapeutic change in these disorders. 2. clients suffering from all investigated disorders may benefit from treatments or particular interventions that facilitate the development of self-compassion or shame management. 38
  39. 39. Inspiration 39
  40. 40. Inspiration 40  With regard to the critique of the Self-Compassion Scale (see e.g. Muris, Otgaar, Pfattheicher, 2018) we recommend to replicate this study with another measure of self-compassion, such as the Sussex- Oxford Compassion for the Self Scale (SOCS-S; Strauss, Gu, 2018). As a measure of shame we recommend to use the Internalized Shame Scale (ISS; Cook, 2001; Benda, Kadlečík, Dvořáková, in press).
  41. 41. Inspiration 41  It would be desirable to closely compare findings of transdiagnostic research, research on self-compassion and research on shame. We believe, that these so far rather independent research streams have much to offer each other.  The same can probably be said for therapies focused on the treatment of shame and on the development of compassion or self-compassion (Boersma et al., 2015; Desmond, 2016; Germer, 2009; Gilbert, 2010; Jazaieri et al., 2014; Neff, 2011a; Reddy et al., 2013; Schoenleber, Gratz, 2018).
  42. 42. Inspiration 42 Another interesting comparison could then be made between existing knowledge of self-compassion, shame and some relevant new findings of neuroscience research (see e.g. Stevens, Woodruff, 2018; Porges, 2011, 2017).
  43. 43. Acknowledgements  This research was partly supported by the Grant Agency of the Charles University under research Grant No. 44317.  We would like to thank the medical staff of  Psychiatric Hospitals in Červený Dvůr, Kosmonosy, Kroměříž, Havlíčkův Brod, Prague- Bohnice, and Opava,  Anabell Center in Prague, Kaleidoskop - Center for therapy and education in Prague, the Psychotherapeutic and Psychosomatic Clinic ESET in Prague, Fokus Praha, Hélio - Center for Mental Health in Prague  Departments of Psychiatry at the General University Hospital in Prague, the Military University Hospital Prague, the Institute for Clinical and Experimental Medicine in Prague, the University Hospital Olomouc, the Military Hospital Olomouc and the Regional Hospital Jičín  for their kind cooperation.  Special thanks to prim. MUDr. Jiří Dvořáček and prim. MUDr. Adéla Stoklasová. 43
  44. 44. Thank you for your attention! 44 This presentation can be downloaded from: www.jan-benda.com Contact: psychoterapeut@gmail.com
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  51. 51. How to cite this presentation:  Benda, J., Kadlečík, P., Kořínek, D., Dvořáková, M., Vyhnánek, A., & Zítková, T. (2018). Self-compassion and shame-proneness in five different mental disorders: Comparison with healthy controls (Presentation). Roots and Gifts of Integrative Psychotherapy - The 9th Conference of the European Association of Integrative Psychotherapy. Prague, 12.-14. 10. Retrieved from https://www.slideshare.net/janbenda1 51

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