Examining the relationship between shame and social anxiety disorder: A systematic review

Highlights

• Reviewed the literature on the relationship between shame and social anxiety (SA).

• Proposed shame's relevance to cognitive-behavioral models of SA.

• Most studies reviewed found a significant positive correlation between shame and SA.

• Shame may be related to the etiology and maintenance of SA.

• Treatment implications for social anxiety disorder are discussed.

Abstract

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

Introduction

Social anxiety disorder (SAD), also referred to as social phobia, is a chronic mental disorder characterized by fear of negative evaluation as well as significant apprehension and avoidance across a range of social or performance situations, resulting in marked distress and/or impairment in several domains (American Psychiatric Association, 2013). SAD is the fourth most common psychological disorder, with a twelve-month prevalence rate of 6.8% in the US (Kessler, Chiu, Demler, & Walters, 2005) and 2.4% globally (Stein et al., 2017). Further, up to 10% of the population experiences subthreshold social anxiety (SA), which is also associated with significant distress and socioeconomic impairment (Davidson, Hughes, George, & Blazer, 1994; Fehm, Beesdo, Jacobi, & Fiedler, 2008). Taken together, the cumulative impact of SAD and subthreshold SA is substantial. Therefore, understanding the factors that contribute to the etiology and maintenance of SA is imperative. In this systematic review, we examine the role of shame in SAD as a psychological disorder and SA as a dimensional construct.

Shame is often characterized as a painful emotional experience (Gilbert, 1998). Consistent with the appraisal theory of emotions, which asserts that emotions are elicited by evaluations of and assumptions about events and situations (Scherer, Schorr, & Johnstone, 2001), shame has been referred to as a self-conscious emotion because like guilt, humiliation, and other similar emotions, it is implicated in processes of self-evaluation and self-reflection (e.g., Fergus, Valentiner, McGrath, & Jencius, 2010; Gilbert & Miles, 2000, M. Lewis, 1995). The central appraisal in shame involves negative self-evaluation (M. Lewis, 1995). Specifically, shame is thought to occur when one makes internal, stable, and uncontrollable attributions of failure (Tangney & Dearing, 2002; Tracy & Robins, 2004). In other words, shame is focused on the wrongness of one's traits or what one's behaviors indicate about who one is as a person. Shame is also associated with a number of other experiential elements. Consistent with cognitive-behavioral (J.S. Beck, 2011) and dialectical behavioral (Linehan, 2015) models of emotions, we view shame as a complex human experience that encompasses particular cognitive patterns (e.g., believing oneself to be defective), behaviors (e.g., withdrawing from or avoiding interactions with others), and physiological sensations (e.g., feeling a pit in one's stomach), and which can also be accompanied by other emotions (e.g., humiliation, sadness).

Several theorists have proposed that shame may be associated with a number of core features of SA, including self-critical cognitions, social avoidance, interaction anxiety, and distress (Buss, 1980; Cox, Fleet, & Stein, 2004; Gilbert, 2000; Gilbert & Procter, 2006; Harder, Rockart, & Cutler, 1993; Lutwak & Ferrari, 1997; Moscovitch, 2009). The cognitions associated with shame and SA are strikingly similar. As a self-conscious emotion, shame involves viewing oneself or one's attributes as lacking, lesser than, or defective (H.B. Lewis, 1971). In comparison, the perceived negative evaluation central to SAD boils down to the belief that one has failed or will fail to meet others’ expectations (Rapee & Heimberg, 1997). Likewise, shame and SA share common behavioral manifestations, including withdrawal, avoidance, and submissive behaviors (e.g., Gilbert, 2000; Piccirillo, Dryman, & Heimberg, 2016; Wells et al., 1995). Taken together, the conceptual overlap between SA and shame is substantial, and it seems highly unlikely, perhaps even impossible, to experience significant SA, and certainly diagnosable SAD, without experiencing some level of shame.¹

Although our review focuses on the maladaptive ways in which shame may be related to the development and maintenance of SAD, it is important to acknowledge the evolutionary theory of emotions, which suggests that all emotions have an adaptive function (e.g., Frijda, 2016). Research suggests that experiencing transient, mild to moderate levels of both shame and SA can be helpful in several contexts (see McNeil, 2010; Sznycer et al., 2016). For example, shame can be triggered by perceived threat to a social bond (H.B. Lewis, 1971; Scheff, 2003) or one's social status (Gilbert, 1989, Gilbert, 1992) and can motivate individuals to minimize the exposure of negative information about themselves to prevent the loss of a social bond or social status (Sznycer, 2019). Likewise, SA is thought to have evolved to minimize social threats by appeasement and sacrifice of status (Gilboa-Schechtman, Shachar, & Helpman, 2014). Therefore, in the face of actual social threat, both shame and SA can motivate individuals to avoid conflict, which, from an evolutionary standpoint, keeps the tribe together and increases one's chances of survival. Nevertheless, high trait (i.e., global and stable) levels of any painful emotion, including shame and SA, may result in maladaptive outcomes. Indeed, high levels of trait shame are consistently related to various forms of psychopathology (e.g., Tangney, 1991; Tangney, Stuewig, & Mashek, 2007; Tangney, Wagner, & Gramzow, 1992).

In the following section, we begin by summarizing literature investigating the empirical association between shame and SA. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of SAD (Heimberg et al., 2014). We propose how shame may interact with several components of the model and discuss how the current literature base supports (or fails to support) these propositions. We then discuss existing research on the role of shame in the treatment of SAD and propose treatment implications of the research discussed in this review. We close with a discussion of limitations and future directions.