Behavioral and characterological self-blame in chronic obstructive pulmonary disease

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Abstract

Objective

To assess behavioral and characterological self-blame, identify demographic and relational correlates of self-blame, and determine the association of self-blame with psychological and clinical outcomes of chronic obstructive pulmonary disease (COPD).

Methods

Data were collected via self-report questionnaires completed by 398 individuals with COPD who had at least a 10 pack-year history of smoking. Behavioral and characterological self-blame were measured, and multiple regression was used to identify correlates of both types of self-blame. Multiple regression was also used to determine the association of self-blame with outcomes of COPD.

Results

More than one-third of participants endorsed the maximum possible score on the measure of behavioral self-blame. The perception that family members blamed the individual for having COPD (p = .001), tobacco exposure (p = .005), and general family functioning (p = .002) were associated with behavioral self-blame. Current smoking status (p = .001) and perception of blame from family (p < .001) were associated with characterological self-blame. While behavioral self-blame was associated with fewer symptoms of depression (p = .02), characterological self-blame was associated with more symptoms of depression (p = .02).

Conclusions

Individuals with COPD tend to blame themselves for smoking and other behaviors that may have led to their COPD. Smoking-related variables and the perception that family members blamed the individual for having COPD were associated with self-blame. Findings support the importance of distinguishing between behavioral and characterological self-blame in COPD, as behavioral self-blame had a negative association with depression and characterological self-blame had a positive association with depression.

Introduction

Chronic obstructive pulmonary disease (COPD) is an incurable disease characterized by progressive shortness of breath. In addition to impairment in quality of life, patients with COPD experience psychological and social consequences of COPD that include depression, anxiety, and social isolation [1], [2], [3]. Qualitative research indicates that people with COPD consider it to be a self-inflicted health condition and feel shameful about their prior smoking [4], [5]. Given that 80–90% of cases of COPD in the US are due to smoking [6], [7], self-blame may be a particularly important aspect of living with COPD. It is unclear who is most likely to experience self-blame. Two studies have reported that age is not associated with self-blame [8], [9]; however, one study indicates that older individuals are less likely to report self-blame [10]. A study of women with rheumatoid arthritis found that having a critical husband is associated with increased self-blame [11]. These studies indicate that demographic and relational characteristics may help to identify individuals who are more likely to experience self-blame.

In previous research, self-blame has been conceptualized as a coping mechanism [8], [10], [12], [13], [14] or an attribution [9], [15], [16] used to manage chronic illness. Results of studies that conceptualize self-blame as a single construct for managing chronic illness suggest that self-blame is maladaptive. For example, two studies have demonstrated a positive association between self-blame and depression [8], [12]. Research has also demonstrated an association between self-blame and decreased quality of life in patients with heart failure [8].

Janoff-Bulman has conceptualized self-blame as consisting of two related but distinct types of blame: behavioral self-blame and characterological self-blame [17]. Behavioral self-blame occurs when an undesirable outcome is blamed on specific behaviors or actions. Characterological self-blame occurs when an undesirable outcome is blamed on one's own character or disposition. Janoff-Bulman has hypothesized that characterological self-blame is maladaptive because blame is placed on non-modifiable factors (i.e., one's own character). In contrast, behavioral self-blame is adaptive, as the blame is placed on modifiable factors (i.e., behavior) [17]. Contrary to these hypotheses, both behavioral and characterological self-blame have been associated with poorer psychological adjustment in women with rheumatoid arthritis [11] and breast cancer [9]. Other research indicates that characterological but not behavioral self-blame is related to greater maladjustment [14], and that behavioral self-blame is related to distress only when the individual also experiences characterological self-blame [15].

Although self-blame has been studied in health conditions such as cancer [15], genital herpes [14], rheumatoid arthritis [11], inflammatory bowel disease [16], and irritable bowel syndrome [18], no quantitative research to date has investigated self-blame in COPD. COPD is an ideal illness in which to study self-blame, since the vast majority of cases of COPD in the US are directly linked to a personal health behavior: tobacco smoking. The objectives of the present study were to assess the extent of behavioral and characterological self-blame, identify demographic and relational correlates of self-blame, and determine the association of self-blame with psychological and clinical outcomes of COPD. By measuring both behavioral and characterological self-blame, we were able to test the hypothesis that behavioral self-blame is adaptive while characterological self-blame is maladaptive.

Section snippets

Sample and procedures

This protocol was approved by the Institutional Review Board at National Jewish Health and the Colorado Multiple Institutional Review Board. Cross-sectional data were collected from individuals with physician-diagnosed COPD by mailing questionnaires to people who had been assessed or treated for COPD at two medical centers in Denver. These two medical centers were chosen to generate a large and diverse sample. One medical center was a tertiary-care respiratory hospital and the other was a

Results

Characteristics of the sample are in Table 1. Nearly half of the sample (48.24%) was female and less than 40% of the sample was younger than age 65. More than half of the sample was married or a member of an unmarried couple (58.04%). Only 16.08% of the current sample was current smokers. On average, participants had smoked 55.61 pack-years (SD = 28.63). Overall, participants did not perceive their family as critical or blaming. The mean score for perceived criticism was 3.99 (SD = 3.40) and the

Discussion

COPD is an ideal illness in which to study self-blame, since the vast majority of cases of COPD in the US are directly linked to tobacco smoking. Participants in the current study endorsed a high level of behavioral self-blame—more than one-third of participants endorsed the maximum possible score on behavioral self-blame. This indicates that participants blame themselves for smoking and other behaviors that may have contributed to the development of their COPD. Behavioral self-blame was

Source of funding

This work was supported by the National Institutes of Health grants F32 HL083687, K23 HL091049, and UL1-RR025780.

Conflict of interest

No conflicts of interest.

Acknowledgments

We thank Russell Bowler, MD, PhD; Barry Make, MD; Christina Schnell, BA, CCRC; Richard Albert, MD; Thomas MacKenzie, MD, MSPH; Holly Batal, MD, MBA; Rebecca Hanratty, MD; and Jeanne Rozwadowski, MD; for their help in recruiting participants for this study.

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