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Self-blame Attributions of 

Patients: a Systematic Review 

Study 

 

Yadollah Jannati1, Hamid Sharif 

Nia2, Erika Sivarajan Froelicher3,4, 

Amir Hossein Goudarzian5*, 

Ameneh Yaghoobzadeh6 
 
1Psychiatry and Behavioral Sciences Research 

Center, Mazandaran University of Medical 

Sciences, Sari, Iran; 
2Amol School of Nursing and Midwifery, 

Mazandaran University of Medical Sciences, 

Sari, Iran; 
3Department of Physiological Nursing, School 

of Nursing, University of California San 

Francisco, San Francisco, California, USA; 
4Department of Epidemiology & Biostatistics, 

School of Medicine, University of California 

San Francisco, San Francisco, California, 

USA;  
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5Student Research Committee, Mazandaran 

University of Medical Sciences, Sari, Iran;  
6School of Nursing and Midwifery, Tehran 

University of Medical Sciences, Tehran, Iran 

 

*Corresponding author 

 

Vol. 9, No. 1 (2020)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2020.419   |   http://cajgh.pitt.edu 

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Abstract 

Introduction: Psychological aspects are important issues in patients that will have significant effects on disease progression. A 

new and important psychological concern is self-blame. This review was performed with the aim of systematic review on studies 

around patient’s self-blame. 

Methods: This is a systematic review using international databases including PubMed (since 1950), Scopus (since 2004), Web of 

Sciences (since 1900), and ProQuest (since 1938) and Iranian databases including SID (since 2004) and Magiran (since 2001). 

Mesh terms including “patient,” “regret,” and “guilt” and non-Mesh terms including “self-blame attribution,” “characterological 

self-blame,” “behavioral self-blame,” and “blame” were used in Iranian and international databases with OR and AND operators. 

Results: The review yielded 59 articles; 15 articles were included in the present study. The ages of patients ranged from 29-68.4 

years. Most of studies (86.6%) had cross-sectional design and use characterological self-blame and behavioral self-blame variables 

for assessing self-blame attributions. The results showed that in most studies, a significant relationship among self-blame and 

psychological distress, anxiety, and depression were reported. 

Conclusion: A significant relation was reported between self-blaming and the degree of distress, anxiety, and depression in patients 

in most of the studies. 

Keywords: Self-blame; Patient; Anxiety; Depression; Systematic review  

Self-blame Attributions of Patients: a 

Systematic Review Study 

 

Yadollah Jannati1, Hamid Sharif Nia2, 

Erika Sivarajan Froelicher3,4, Amir 

Hossein Goudarzian5, Ameneh 

Yaghoobzadeh6 

 
1Psychiatry and Behavioral Sciences Research 

Center, Mazandaran University of Medical 

Sciences, Sari, Iran;   
2Amol School of Nursing and Midwifery, 

Mazandaran University of Medical Sciences, Sari, 

Iran;  
3Department of Physiological Nursing, School of 

Nursing, University of California San Francisco, 

San Francisco, California, USA;  
4Department of Epidemiology & Biostatistics, 

School of Medicine, University of California San 

Francisco, San Francisco, California, USA; 
5Student Research Committee, Mazandaran 

University of Medical Sciences, Sari, Iran;  
6School of Nursing and Midwifery, Tehran 

University of Medical Sciences, Tehran, Iran 

Research 

Vos et al. estimated about 95% of the world's 

populations are suffering from a variety of physical 

health problems1. Cancer, cardiovascular disease, 

chronic obstructive pulmonary disease (COPD), and 

diabetes are the most common health problems in the 

world. Though at a lower incidence, populations also 

suffer from diseases such as acquired immunodeficiency 

syndrome (AIDS), kidney disease, and hypertension2. 

These are chronic conditions that typically require long-

term care throughout life and often have many physical, 

psychological, and social challenges for the patient and 

their families3. 

Psychological aspects are some of the most 

important problems these patients experience, and they 

have significant effects on the progression of their 

disease4. The psychological adaptation to these stressful 

life events needs to be assessed, including cognitive 

effects. Cognitive assessments are important in 

determining these effects, explored/identified through 

factors like self-blame5. Self-blame is a common reaction 

to stressful events and has certain effects on how 

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individuals adapt. Types of self-blame are hypothesized 

to contribute to depression, and self-blame is a 

component of self-directed emotions like self-guilt and 

self-disgust. Because of self-blame’s commonality in 

response to stress and its role in emotion, self-blame 

should be examined using psychology’s perspectives on 

stress and coping5,6. Janoff-Bulman suggested that 

behavioral self-blaming has a direct relation with the 

level of health and the ability to control stress. Because 

these chronic conditions persist over many years and are 

often unstable, they have a damaging effect on 

psychological well-being6. Many studies with patient 

samples other than cardiovascular disease confirmed the 

hypothesis that behavioral self-blaming is directly related 

to better health findings than characterological self-

blaming5,7,8.  

Numerous other studies have been conducted 

about self-blaming in patients5,9-12; though some 

contradictions are still presented. For example, the 

relationship between behavioral self-blaming and 

characterological self-blaming and psychological 

disorders was investigated in a study on cardiovascular 

patients receiving cardiac rehabilitation exercises12. The 

results indicated that behavioral self-blaming had a 

positive effect on the level of anxiety and depression at 

the beginning of exercise. Characterological self-

blaming, however, did not have any definite relationship 

with these variables. Both types of self-blaming were 

good predictors of cardiac psychological symptoms in 

patients with cardiac rehabilitation in other studies10. The 

results of this study showed that both types of self-

blaming initially had a positive relationship with the 

symptoms of heart disease, but only  characterological 

self-blaming was a predictor of outcomes in the ensuing 

21 months. 

 Therefore, studies on self-blaming of patients 

needed to be made comprehensively by means of an 

instrument that emphasizes both categories of blaming. 

Considering the contradictory information across studies 

it seems necessary to do a review of all available 

literature on this topic to better understand the 

relationship between self-blaming and psychological 

disorders in different populations. Therefore, considering 

the necessity of a comprehensive review, the present 

study was conducted with the aim of systemically 

reviewing studies in the field of self-blaming in patients, 

with the intent of exploring if self-blame is associated 

with any particular type of medical conditions. 

 

Methods 

This systematic review was conducted in 

accordance with PRISMA guidelines 201913. This study 

reports on a systematic review of studies in the field of 

self-blaming. 

Search strategy and studies’ criteria 

A systematic review of related studies 

conducted in the international databases in the English 

and Farsi literature of PubMed (since 1950), Scopus 

(since 2004), Web of Sciences (since 1900), and 

ProQuest (since 1938) and Iranian databases of SID 

(since 2004) and Magiran (since 2001). Based on table 1, 

Mesh terms including “patient”, “regret” and “guilt” and 

non-Mesh terms including “self-blame attribution”, 

“characterological self-blame”, “behavioral self-blame” 

and “blame” were chosen to search using OR and AND 

operators in Iranian and international databases, 

respectively. All original articles were collected and 

reviewed for inclusion in the study. First, the published 

articles related to the aim of the present study were 

reviewed by the two researchers (AHG and HSH). The 

initial list was then entered into Endnote to eliminate 

duplicate studies if present. In the third stage, the articles 

were examined and filtered based on inclusion and 

exclusion criteria. Inclusion criteria were: 1) the key 

words (including self-blame, characterological self-

blame, behavioral self-blame, and blame) presented in 

title or abstract; 2) published in Persian or English 

language; 3) self-blaming considered as the independent

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Databases Search strategy 
Preliminary 

searches 

Formal screening 

of search results 

against eligibility 

criteria 

PubMed 

 [(Self-blame attribution) OR Blame] OR [Regret OR 

Guilt) AND Patient 

9,704 9 

Scopus 2,365 3 

Web of Science 3,921 2 

ProQuest 91,955 1 

SID 67 0 

Magiran 280 0 

Table 1. Database search stages 

variable; 4) only subjects with a physical diagnosis were 

included (due to the fact that there are differences 

between these patients and the ones with mental 

disorders, which makes it difficult to reach accurate 

conclusions). Published studies in the form of 

dissertations, books, and abstracts of congresses and 

conferences were also excluded from the study, due to 

insufficient details and lack of peer review. Review 

studies were also excluded from the study. Also, articles 

with access limitation to the full text were received in 

correspondence with the author. 

Based on Table 1 and Figure 1, from 108,292 

articles that were found from all of databases, 51 articles 

were extracted. After across mentioned criteria, 36 

articles were excluded. Then, 15 articles were entered to 

quality assessment stage. 

 

Quality assessment 

The quality of the methodology was verified by 

two researchers (AHG and YJ) independently using the 

STROBE checklist (for cross-sectional studies) and the 

COREQ checklist (for qualitative studies). STROBE 

consists of 22 sections and examines various aspects of 

the methodology, including the objectives of the study, 

sampling methods, variables measurements, statistical 

analysis, confounding modifications, and validity and 

reliability of the measures14. The minimum score was 

considered as 16 for this checklist. Finally, qualified 

studies were entered to the research that obtained a 

minimum score14 using this checklist. Moreover, 

COREQ consists of 32 items, including the researcher's 

profile, the type of study design (sampling methods, 

sample size, type of interview and methodology), and the 

method of analyzing and reporting the results15. The 

minimum score was 23 to be included in the review.  

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Figure 1. PRISMA flowchart 

Data extraction and analysis 

The following information was extracted from 

each paper entered to the study: first author, year of 

publication, study type, number and mean age of 

participants, location of the study, type of population 

surveyed, type of instrument used, and most important 

findings. The validity of the tool was evaluated by 10 

expert faculty members in Mazandaran University of 

Medical Sciences. 

Ethics statement 

This study was approved in Ethic committee of 

Mazandaran University of Medical Sciences 

(IR.MAZUMS.REC.1398.453). 

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Results 

All articles entered into this study were 

reviewed by two checklists. Overall, the quality of 

studies was acceptable.  

In the present study, 15 articles out of 59 articles 

were entered after various stages of screening5,8,16-28. 

Most of them (86.6%) had cross-sectional designs and 

were conducted in the USA (73.3%). Furthermore, most 

of the studies about self-blaming were among patients 

with cancer, but few studies have been conducted on 

patients with heart disease, COPD, burns, Major 

Depressive Disorders (MDD), type 2 diabetes, and 

irritable bowel syndrome (based on Table 2). 

The patient ages ranged from 29 to 68.4. Also, 

most studies used a two-part tool of characterological 

self-blame (CSB) and behavioral self-blame (BSB) to 

evaluate self-blaming. Based on the results, self-blaming 

had a significant relationship with the amount of distress, 

anxiety, and depression in patients. In other words, self-

blaming was associated with mental disorders and 

patients’ quality of life.  

Self-blame and distress 

Some studies were carried out on cancer 

patients, cardiac patients and irritable bowel syndrome 

around the relationship of self-blame and psychological 

distress (Table 2). Malcarne in his study that was done on 

72 cancer patients (near diagnosis) declared that 

characterological self-blame was related to higher levels 

of psychological distress in the first of study (time 1) and 

Time 2 (4 months after) [r(70) = .38, p < .001] but 

behavioral self-blame not related to psychological 

distress in Time 216. Initial psychological distress was a 

significant predictor of characterological self-blame (sr 2 

= .53, p < .001, β = .74), and the interaction of behavioral 

and characterological self-blame was significant (sr 2 = 

.02, p < .05, β = .18). Bennett released that BSB in cardiac 

patients was predictive of baseline levels of anxiety 

symptoms (β=0.28, p<0.01, sr2=0.06), as well as Time 2 

(12 weeks later than cardiac rehabilitation program) 

symptoms after controlling for baseline levels (β=0.23, 

p<0.01, sr2=0.04)28. That is, blaming one’s behavior for 

a cardiac event was positively related to experiencing 

symptoms of anxiety concurrently and 12 weeks later. 

Self-blame with anxiety and depression 

Else-Quest concluded that self-blame was 

negatively correlated with self-esteem (r = -0.26, 

p<0.001), but positively correlated with anxiety (r = 0.55, 

p<0.001), anger (r = 0.53, p<0.001) and depressed affect 

(r = 0.55, p<0.001)18. Self-blame also has a mediating 

role on the effect of perceived stigma on adjustment. The 

Bennett study on cardiac patients showed that BSB was 

positively related to baseline depressive symptoms 

(β=0.38, p<0.001, sr2=0.11), and it predicted symptoms 

of depression at Time 2 after controlling for baseline 

levels (β=0.14, p<0.05, sr2=0.01)28. Another research on 

newly diagnosed breast cancer patients declared that, at 

diagnosis, the regression equation was significant in 

predicting anxiety and depression symptoms, accounting 

for 20% of the variance8. Level of distress was predicted 

by behavioral self-blame; greater behavioral self-blame 

was predictive of more anxiety and depression 

symptoms, accounting for 9% unique variance. 

Characterological self-blame was not significantly 

associated with affective symptoms. When behavioral (β 

= .38, sr2 = .14) and characterological self-blame (β = .28, 

sr2 = .08) were entered separately, both were significant 

predictors of anxiety and depression symptoms8. 

In the Kiecolt-Glaser study, the burn patients’ 

self-blame had a significant relation with depression (r = 

0.15, β = 0.32, p<0.05), but no significant relation was 

seen with anxiety20. Phelan, in a study on colorectal 

cancer patients, also concluded that self-blame was 

significantly associated with depressive symptoms (b = 

2.67, p<0.001). The perception that other people blame 

the individual with colorectal cancer for the disease 

remained non-significant (b = -0.58, p = 0.56)25. 

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Other related factors 

One of the important factors that was assessed 

by Friedman on breast cancer patients was quality of 

life21. Self-blame, spirituality, and employment status 

were significant predictors of quality of life, accounting 

for 47% of the variance (p<0.001). Also the results from 

the multiple regression analyses show self-blame, self-

forgiveness, and spirituality were significant predictors 

of mood disturbance, accounting for 50% of the variance 

(p<0.001)21. Sholomskas stated that self-blaming had no 

significant relationship with coping skills in spinal injury 

patients17. Also one concept that was focused in some 

studies was self-blaming rumination that effects on 

psychological distress and other related psychological 

diseases including depression29.

Author  

(year) 
Study type Place Participants (n) 

Mean age 

(SD) 
Study tool Important findings 

Malcarne  

(1995) 
Cross-sectional USA 

Cancer patients 

(72) 
45.46 (7.49) 

BSB and 

CSB 

Psychological distress 

was an important 

predictor of self-blame. 

Bennett  

(2005) 
Cross-sectional USA 

Breast cancer 

patients (53) 
53 (9.4) 

BSB and 

CSB 

Self-blame was an 

important predictor of 

anxiety and depression. 

Sholomskas  

(1990) 
Cross-sectional USA Spinal damage (31) 29 

Causal 

Dimension 

Scale (CDS) 

There was no 

relationship between 

self-blame and patient 

coping behaviors. 

Else-Quest  

(2009) 
Cross-sectional USA 

Lung, prostate and 

breast cancer 

patients (172) 

66.9 (11.18) 

The State 

Shame and 

Guilt Scale 

(SSGS) 

Self-blame was an 

important predictor of 

anxiety, anger and 

depression. 

Bennett  

(2013) 
Cross-sectional USA 

Cardiac patients 

(129) 
64.1 (10.2) 

BSB and 

CSB 

BSB was associated with 

mental distress at the 

beginning of the 

trainings. 

Zahn  

(2015) 
Cross-sectional England MDD (132) 32.8 (12.3) 

Psycho-

pathology-

based 

instrument 

(AMDP) 

Self-blame was high in 

MDD patients, but it was 

not the cause of sin. 

Glinder  

(1999) 
Cross-sectional USA 

Breast cancer 

patients (76) 
54.8 (9.8) 

BSB and 

CSB 

Self-blame was an 

important predictor of 

anxiety and depression. 

  

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Kiecolt-Glaser 

(1987) 
Cross-sectional USA Burn patients (49) 

35.87 

(13.44) 

BSB and 

CSB 

The higher BSB 

predicted depression and 

inconsistency. 

Friedman  

(2007) 
Cross-sectional USA 

Breast cancer 

patients (123) 
56.2 (11.5) 

BSB and 

CSB 

Self-blame was an 

important predictor of 

anxiety and depression. 

Sheridan 

(2011) 
Qualitative 

New 

Zealand 
COPD (29) - Interview 

Self-blame has increased 

the sense of need. 

Halding  

(2010) 
Qualitative Norway COPD (18) - Interview 

Self-blame was 

remarkable in these 

patients. 

Phelan  

(2011) 
Cross-sectional USA 

Colorectal cancer 

(1109) 
68.4 (10) 

Researcher 

made 

Self-blame was an 

important predictor of 

depression. 

Friedman  

(2010) 
Cross-sectional USA 

Breast cancer 

patients (108) 
52 

BSB and 

CSB 

Self-blame was 

associated with quality 

of life. 

Beverly  

(2012) 
Qualitative USA 

Type 2 diabetes 

(34) 
59.8 (7.3) Interview 

Self-blame was 

responsible for poor 

achievement for medical 

purposes. 

Alisha  

(2000) 
Cross-sectional Canada 

Irritable bowel 

syndrome (25) 
- 

BSB and 

CSB 

Self-blame was an 

important predictor of 

psychological distress. 

Table 2. Characterization of included articles

Discussion 

There are numerous studies about self-blaming; 

this is still an important and new subject throughout the 

world. One important conclusion of this review is that 

self-blaming is a significant predictor of psychological 

distress, anxiety, and depression in patients. It is 

problematic when it appears as self-blaming 

rumination30. Self-blaming rumination is a form of 

intellectual rumination and negative recurring thinking 

with the purpose of underestimating oneself. Moreover, 

researchers have suggested that it is associated with 

psychological problems such as depression, anxiety, and 

anger31. Self-blaming is a form of inadequate self which 

is correlated with marital conflicts32. Also, it is related to 

disappointment and indifference about others, that is, 

they feel apathy about them33. Abi-Habib and Luyten 

found in their research that these kinds of people behaved 

in a hostile and biased manner against others34. They are 

anxious and hardly in control of their anger towards 

others, which often leads to conflicts in interpersonal 

relationships. 

So far, most of the studies about this 

phenomenon have been conducted in samples of US 

populations. Cancer patients were the most emphasized 

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sample, cardiac and COPD patients were the next grades. 

Unfortunately, no attention has been paid to this very 

important issue on patients in Iran. However, Kochaki et 

al. conducted a study about the mediating role of self-

blaming rumination in the relationship between 

disaffection and marital violence. They stated that self-

blaming can’t predict marital violence35. It needs to 

consider that the sample population of this study was 

community samples who have different mental and 

physical conditions compared to populations of patients 

with medical diagnosis.  

Patients are subjected to suffering from various 

psychological changes due to possible changes in their 

organs (because of the process of disease or surgical 

procedures) and the reductions of energy and activities 

associated with such illnesses. Changes in their self-

concept is one of the most common and destructive 

changes36. Patients with disrupted self-concept tend to 

blame themselves. It can lead to giving up against the 

disease in extreme cases, which can have adverse health 

effects for the patients. Paying attention to this 

phenomenon will greatly contribute to the health and 

wellbeing of a community in terms of manpower and 

medical expenses. 

The hopelessness theory of depression proposes 

that depression is caused by two variables: attribution of 

negative events to stable and global causes, and other 

cognitive factors like low self-esteem37. CSB attributes 

occurrence of events to stable aspects of the individual 

that are not controllable. CSB attributions seem likely to 

cause helplessness, since individuals believe they are 

powerless to control the characteristics that lead to 

negative events38. On the other hand, BSB has an 

indeterminate effect under hopelessness theory, since 

BSB attributes events to behaviors that can be controlled 

to produce better outcomes38. These theories of 

attributional style and stress and coping have similar 

predictions to Janoff-Bulman’s BSB/CSB distinction6. 

Depression occurs when individuals feel that they cannot 

control the future. The CSB/BSB distinction also 

corresponds to Dweck’s distinction between ability and 

effort attributions39. Effort attributions are when 

individuals assign success or failure to the hard work and 

other controllable factors, while ability attributions 

assign outcomes to internal, stable characteristics, like 

intelligence. Dweck noted that individuals that believe 

outcomes are uncontrollable are more likely to be 

debilitated by setbacks, procrastinate or avoid stressors, 

and show greater stress responses39. In short, theorists 

believe that the type of cause to which events are 

attributed is a central factor of effectiveness of blame40. 

Exploratory neuroscientific evidence has found 

a distinct sign of connectivity abnormality associated 

with general self-blame. Evidence suggests that major 

depressive disorder creates vulnerability to depression 

that lasts years after the cessation of depressive 

episodes41. One of the mechanisms of this “scar theory” 

of depression is proposed to be increased likelihood to 

perform self-blame. Self-blaming biases are present in 

patients with remitted depression, and these biases are 

associated with risk of recurrence of MDD41. Researchers 

used functional magnetic resonance imaging (fMRI) to 

examine brain regions and connections associated with 

self-blame. Abnormal activation was demonstrated in 

subgenual cingulate cortex and septal area (SCSR) in 

currently depressed individuals, but in other situations as 

well: previously-depressed individuals showed 

differences in brain activity while feeling guilt compared 

to always-healthy controls42. Also, the amount of 

connection abnormality in these regions was predictive 

of depression recurrence42. These data suggest that 

depression episodes change the quality of self-blame, 

making individuals vulnerable to depression recurrence. 

The result of this systematic review reveals the 

fact that the issue of self-blaming is very important and 

is also a key for all groups of society, especially patients. 

Unfortunately, this issue has not been adequately 

considered in Iran. By emphasizing the use of specific 

tools to measure self-blaming for patients, some 

interventions can be initiated to treat these disorders. 

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JANNATI 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 9, No. 1 (2020) | ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.419 | http://cajgh.pitt.edu 

 

 

Moreover, the practice of using this tool and its necessity 

can be taught in the universities and especially in nursing 

schools (due to the high level of nurse-patient 

relationship). The collection of all these suggestions can 

be effective over time for the health of patients, as well 

as their families, which helps to reduce the burden of 

treatment on the country's side, in addition to promoting 

the country's health index in the world. 

This study had some limitations like other 

studies. One of the most important was the shortage of 

articles for more definitive and stable conclusions. Also, 

no relevant studies were found on patients in Iran that 

allowed us to compare our findings with other 

communities. Most of the focus was on cancer patients, 

so a more accurate comparison between patient 

populations was not possible. Given only seven databases 

were used in the study, the possibility exists that certain 

relevant publications containing self-blame measures 

were not identified, a common challenge when 

conducting systematic reviews. Furthermore, given our 

initial review targeted article abstracts, it is plausible that 

information about the measures were included in the text 

of omitted articles. 

Therefore, it is recommended that future studies 

be carried out on well-defined population of patients. Of 

course, it is important to note that the tool to measure 

self-blaming has not been validated in Iran. So, it needs 

to be validated in a Farsi-speaking Persian sample. Now 

we know that self-blame had significant relation with 

some important psychological factors like depression and 

anxiety, so we can design and run some randomized 

clinical trial studies to assess the exact effects of reducing 

self-blame on those negative psychological factors. 

In summary, a significant relation was reported 

between self-blaming and the degree of distress, anxiety, 

and depression in patients in most of the studies. It is 

recommended to do further studies to evaluate this 

finding. 

 

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