Shame In OCD: A Systematic Review and Meta‐Analysis

Due to rumination and self‐criticism over unwanted obsessions and repetitive rituals, shame is a common emotion experienced by individuals with obsessive–compulsive disorder (OCD). Shame is also theorized to have relevance to unacceptable thoughts in OCD. However, empirical research looking at the relationship between OCD and shame is still emerging and findings have been mixed.

Laving, M., Foroni, F., Ferrari, M., Turner, C., & Yap, K. (2023). The association between OCD and Shame: A systematic review and meta-analysis. British Journal of Clinical Psychology, 62, 28–52. https://doi.org/10.1111/bjc.12392

Key Points

• This was the first meta-analysis focused solely on shame in OCD, providing a clearer picture of this relationship.
• The findings align with cognitive models proposing shame develops from dysfunctional appraisals of intrusive thoughts.
• The study highlights shame may be particularly relevant in symptoms involving internal triggers like unacceptable thoughts and symmetry concerns.
• A significant, moderate and positive correlation was found between total OCD severity scores and shame (r = .352). This indicates a medium likelihood that individuals with OCD will also experience shame.
• Weak but significant positive correlations were found between shame and three OCD symptom dimensions – Unacceptable Thoughts (r = .252), Harm (r = .224), and Symmetry (r = .200).
• No significant relationship was found between shame and Contamination concerns (r = .0875).

Rationale

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive rituals.

Cognitive models propose that feelings of shame can emerge in OCD due to dysfunctional appraisals about obsessional thoughts, which can perpetuate negative self-beliefs (Bhar & Kyrios, 2007).

However, empirical research on shame in OCD has provided mixed results (Cândea & Szentagotai-Tăta, 2018).

This systematic review and meta-analysis aimed to clarify the association between shame, OCD and unacceptable thoughts.

Method

• The literature was systematically searched across 5 databases using keywords related to shame and OCD.
• The included studies were peer-reviewed, published in English, used validated OCD and shame measures, and provided correlational data between them.
• 18 studies were included in the primary meta-analysis of OCD severity and shame.
• A separate analysis with 3 studies examined shame correlations with 4 OCD symptom dimensions.
• The pooled correlations were calculated using a random effects model.

Sample:

• The samples included clinical, community, and undergraduate groups from several countries, including the USA, Italy, and South Korea.
• Ages ranged from 18.7 to 40.62 years old. More studies had predominantly female participants.

Statistical measures:

• The effect size reported was the Pearson correlation coefficient (r), converted to Fisher’s Z and aggregated using Comprehensive Meta-Analysis software in the primary analysis, and Jamovi software in the symptom dimension analysis.
• Heterogeneity was measured with the Q and I2 statistic. Trim and fill analysis assessed publication bias.

Results

• A moderate, significant correlation was found between total OCD scores and shame (r = .352).
• Weak but significant correlations were found between shame and 3 OCD symptom dimensions – Unacceptable Thoughts, Harm, and Symmetry.
• No significant relationship was observed between shame and Contamination concerns.

Implications

• As shame can impair functioning and quality of life in OCD, it is imperative to address it through psychoeducation, assessment, and treatment.
• Therapists should know that OCD patients may not readily disclose shameful obsessions and should work to normalize this experience.
• Cognitive behavioral therapy (CBT) for OCD focuses on modifying dysfunctional cognitions, which could help reduce shame arising from distorted thinking patterns like thought-action fusion. However, shame is not directly targeted in CBT. Integrating techniques from compassion-focused therapy or schema therapy may enhance shame reduction.
• On a societal level, reducing the stigma around OCD through public education campaigns could help lessen maladaptive shame in sufferers. Since unacceptable/taboo thoughts elicited the most shame but are often hidden due to stigma, raising awareness of intrusive thoughts as a common OCD feature could encourage help-seeking behaviors.

Future Research

• Considering shame poses barriers to disclosing and treating distressing obsessions, development of implicit or indirect measurement tools could allow for more accurate assessment of shame in OCD. This could enlighten treatment plans.
• Longitudinal research tracking shame and OCD symptoms over time can help determine causality and directionality of this relationship. Experimental studies manipulating variables hypothetically contributing to shame may also prove insightful.
• Examining cultural factors in OCD-related shame across countries and ethnicities can identify unique societal influences shaping this experience. This knowledge could tailor educational and treatment approaches to be culturally sensitive.
• Since high between-study variance suggests other variables are implicated, future research should explore potential mediators like self-disgust, perfectionism, stigma experiences, comorbidities etc. to uncover interaction effects.

Strengths & Limitations

The study had many methodological strengths, including:

• Use of validated OCD and shame measures only;
• Contact with authors to retrieve unreported statistic;
• Rigorous search across multiple databases; assessment of publication bias.

However, this meta analysis was limited in a few ways:

• Variability in shame measures used;
• Social desirability bias may affect self-reports of shame;
• Inability to infer causality from cross-sectional data; heterogeneity between studies was high.

Conclusion

These findings support a medium positive association between shame and OCD overall. Shame appears particularly linked to unacceptable thoughts, harm obsessions, and symmetry concerns.

Further research using OCD-specific shame measures is needed to enrich understanding of this relationship and its clinical relevance.

References

Primary Paper

Laving, M., Foroni, F., Ferrari, M., Turner, C., & Yap, K. (2023). The association between OCD and Shame: A systematic review and meta‐analysis. British Journal of Clinical Psychology, 62(1), 28-52.

Other References

Bhar, S. S., & Kyrios, M. (2007). An investigation of self-ambivalence in obsessive-compulsive disorder. Behaviour Research and Therapy, 45(8), 1845-1857. https://doi.org/10.1016/j.brat.2007.02.005

Cândea, D.-M., & Szentagotai-Tăta, A. (2018). Shame-proneness, guilt-proneness and anxiety symptoms: A meta-analysis. Journal of Anxiety Disorders, 58, 78–106. https://doi.org/10.1016/j.janxdis.2018.07.005

Further Information

• Glazier, K., Wetterneck, C., Singh, S., & Williams, M. (2015). Stigma and shame as barriers to treatment for obsessive-compulsive and related disorders. Journal of Depression and Anxiety, 4(3). https://doi.org/10.4172/2167-1044.1000191
• Singh, S., Wetterneck, C. T., Williams, M. T., & Knott, L. E. (2016). The role of shame and symptom severity on quality of life in obsessive-compulsive and related disorders. Journal of Obsessive-Compulsive and Related Disorders, 11, 49–55. https://doi.org/10.1016/j.jocrd.2016.08.004
• Teroni, F., & Deonna, J. A. (2008). Differentiating shame from guilt. Consciousness and Cognition, 17(3), 725–740. https://doi.org/10.1016/j.concog.2008.02.002

• Visvalingam, S., Crone, C., Street, S., Oar, E. L., Gilchrist, P., & Norberg, M. M. (2022). The causes and consequences of shame in obsessive-compulsive disorder. Behaviour Research and Therapy, 151, 104064. https://doi.org/10.1016/j.brat.2022.104064
• Weingarden, H., & Renshaw, K. D. (2014). Associations of obsessive compulsive symptoms and beliefs with depression: Testing mediation by shame and guilt. International Journal of Cognitive Therapy, 7(4), 305–319. https://doi.org/10.1521/ijct_2014_07_01
• Weingarden, H., & Renshaw, K. D. (2015). Shame in the obsessive-compulsive related disorders: A conceptual review. Journal of Affective Disorders, 171, 74–84. https://doi.org/10.1016/j.jad.2014.09.010
• Wolf, S. T., Cohen, T. R., Panter, A. T., & Insko, C. A. (2010). Shame proneness and guilt proneness: Toward the further understanding of reactions to public and private transgressions. Self and Identity, 9(4), 337–362. https://doi.org/10.1080/15298860903106843
• Yakeley, J. (2018). Shame, culture and mental health. Nordic Journal of Psychiatry, 72(1, Suppl), S20–S22. https://doi.org/10.1080/08039488.2018.1525641

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