“Feelings of worthlessness or excessive guilt or inappropriate guilt” is one of the nine core symptoms of major depressive disorder according to the American Psychiatric Association. Guilt can be an adaptive emotion when it is appropriate to context, is not excessive, is based on altruism (acting with an unselfish regard for others), and serves the purpose of maintaining attachments. However, in depression, guilt tends to be exaggerated or is inappropriate (not relevant to context) and is called maladaptive guilt. Maladaptive guilt presents in depression in one or more of the eight types as described below:
1. Survivor guilt: Survivor guilt first gained attention when survivors from the concentration camps of World War II were noted to harbor feelings of guilt for the loved ones who were killed in the camps. These survivors, years later, developed symptoms of depression and anxiety. Besides combat and natural disasters, survivor guilt has also been observed in medical situations. People who got better following a surgery whereas their family members or friends died of similar or other ailments experienced depressive symptoms following the medical intervention. Research reveals that compared to non-depressed people, people with depression have higher scores on survivor guilt and the higher the survivor guilt, the more severe the depression. Depressed individuals with survivor guilt may ask themselves, “Why me?” as a result of their irrational belief that they don’t deserve to be alive or experience happiness while others have died or are suffering.
2. Guilt about faring better than others: This is a subtle variant of the survivor guilt in which a person may either inhibit themselves from success or engage in self-sabotage as a form of punishment due to the guilt toward another person who they believe to be worse off than themselves. People suffering from this type of guilt may conceal their happiness or success from others, feel uncomfortable when they are doing better than others, and also adapt a more negativistic view of themselves when interacting with other people. These people harbor the irrational thought that attainment of good things is unfair to those or at the expense of those who have not attained them. People with depression often have irrational thoughts such as labeling themselves as selfish or believing that they don’t deserve to feel better that trigger feelings of guilt. Another reason for harboring this kind of guilt is that depressed individuals fear others may envy them because they are doing better. Therefore, they use self-pity to win others’ approval, which temporarily boosts their low-self-esteem.
3. Separation guilt: Separation guilt arises from the irrational belief that one is harming one’s loved ones by separating from them, or by pursuing one’s individual goals, or by being different. The underlying theme in separation guilt is the thought of being disloyal to one’s loved ones. People express separation guilt in statements such as, “I feel that bad things may happen to my family if I don’t stay in close contact with them.” Separation guilt can stem from parents or other important people in one’s life inducing feelings of guilt during one’s childhood years. For example, comments such as, “I stayed in this bad marriage just for you,” or “I sacrificed for you,” or admonitions such as, “You disgrace us,” or “You should be ashamed of yourself” induce guilt-ridden childhood memories. These memories then play out as separation guilt when a person tries to gain approval from their loved ones or others who they see in a parental role.
4. Omnipotent responsibility guilt: This guilt involves a person feeling omnipotently responsible for the happiness and well-being of others without specifically feeling survivor or separation guilt. Omnipotent responsibility guilt can be considered as an exaggerated and irrational form of adaptive guilt. For example, a person with a history of sexual abuse during childhood may carry irrational beliefs that they may be responsible for that or a spouse may have distorted beliefs of blaming themselves for their partner’s unfaithfulness. In depression, the irrational thinking pattern of personalization leads to self-blaming and makes people take too much responsibility for things that may even be beyond their control. People express omnipotent responsibility guilt in statements such as, “I can’t stand the idea of hurting someone else,” “I often find myself doing what someone else wants me to do rather than doing what I would most enjoy,” or “I feel responsible at social gatherings for people who are not able to enter into conversations with others.” This kind of guilt may also arise due to the irrational belief that one may appear less caring, thus risking approval, if one doesn’t assume responsibility for the well-being of others.
5. Guilt of being a burden to others: People with depression may mistakenly believe that they are a burden on their family or loved ones. They feel a sense of guilt and shame in seeking help and may refrain from sharing their difficulties with others. If they are unable to perform at their previous level in an important aspect of life such as work or relationships, they feel that they are not contributing enough for the well-being of the family. This feeling of guilt can, in some people with severe depression, engender suicidal thoughts.
6. Self-hate guilt: In this form of guilt, a person carries an extreme negative view of themselves or a general sense of badness. This type of guilt happens in people who have had harsh, punishing, or neglectful parents or it may serve as a mechanism to avoid survivor guilt. Some expressions for this type of guilt include, “If something bad happens to me, then I must have deserved it,” “I always assume I am at fault when something goes wrong,” or “I don’t deserve other people’s respect or admiration.”
7. Guilt related to grief: Grief can be real or maladaptive after a loss and the latter may happen if one is depressed. An individual with depression, due to irrational thought patterns of personalization, may self-blame following a loss – “I didn’t do enough.” This kind of guilt may also manifest as blaming others when people cannot handle their own sense of culpability and project their guilt onto others. Another presentation of guilt related to grief is the recovery guilt wherein a person goes through the process of grieving and wants to get on their lives but feels guilty that doing so would dishonor the memory of the deceased. Guilt can also arise if one had unresolved conflicts with the deceased and they feel bad about not being able to resolve those before their loved one died.
8. Delusions of guilt: This guilt is present in people with severe depression. The guilt is not based in reality and the person’s beliefs cannot be shaken despite evidence to the contrary. An example of a delusion of guilt is a depressed parent whose child died and they are convinced that they are responsible for the child’s death because they gave the child the wrong medicine when in fact nothing of that sort happened.
Feelings of guilt, like other symptoms of depression, are amenable to treatment either with psychotherapy or medications. To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.
HARPREET S. DUGGAL, MD, FAPA