Vicarious Embarrassment or “Fremdscham”: Overendorsement in Frontotemporal Dementia

Behavioral variant frontotemporal dementia (bvFTD) is predominantly a disorder of socioemotional behavior (1). This neurodegenerative disease involves frontal and anterior temporal lobes resulting in disturbances in social interactions and emotional blunting (2). Investigators have characterized patients with bvFTD as being particularly impaired in self-conscious emotions, which are necessary for the type of feedback that promotes social behavior (3, 4). These include social emotions such as shame, guilt, pride, and, most prominently, the ability to experience embarrassment.

Embarrassment is emotional discomfort associated with perceived social disapproval for violating a social norm (5). Self-embarrassment requires examining one’s behavior through the eyes of others, knowing the social norm violation, and self-appraisal for corrective or reparative actions. It is most intense when the disapproval is directed at the self, but embarrassment may also be experienced vicariously when perceiving social disapproval directed at another; this embarrassment-by-proxy is sometimes referred to by its German name “fremdscham” (6).

bvFTD prominently impairs embarrassment and other self-conscious emotions (7). Patients with bvFTD have decreased emotional reactivity to embarrassing stimuli, such as watching themselves singing (1), decreased self-consciousness (4), and impaired self-awareness from others’ perspective or self-referential processing (3, 4, 8–12). Despite reactivity to simple happy and sad emotional films and facial emotional responses to auditory startle (4, 13), patients in early stages of bvFTD display fewer facial signs of embarrassment than control subjects (4). Finally, bvFTD patients do not show embarrassment and corresponding autonomic reactivity when recognizing their own errors or mistakes (14).

A decreased ability to experience embarrassment may be one of the most basic and early features of bvFTD. Patients with bvFTD are known to have emotional blunting, decreased empathy, and impaired self-referential emotions (3, 4, 7, 13, 15). They exhibit impairment in experiencing embarrassment on an emotional level, although they are able to report embarrassment on a cognitive level (i.e., on the basis of what they believe should be felt) (16). These patients also lack general emotional awareness, often react inappropriately to social norms, and experience difficulties in taking the perspective of others or in mentalization (“theory of mind”) (17–19). All of these deficits may further impair self-awareness of embarrassment. Consequently, an assessment of self-reports of embarrassment in social situations may be a highly sensitive measure for detecting early bvFTD, a disorder for which a definitive clinical test is lacking.

In the present study, we evaluated self-perceived embarrassment among patients with bvFTD compared with normal control subjects. Participants were evaluated with the Embarrassability Scale, containing 36 items equally divided between self and vicarious embarrassment. Participants’ performance on the Embarrassability Scale was compared with their performance on the Social Norms Questionnaire (SNQ), which measures the breaking of or overadherence to social rules as part of the Frontotemporal Lobar Degeneration Module of the National Alzheimer’s Coordinating Center database (20).

Methods

Participants

Participants with bvFTD were recruited from the Behavioral Neurology Program and Clinic at the University of California, Los Angeles (UCLA), where they underwent clinical, neuropsychological, and neuroimaging assessments. Age-matched healthy control subjects (HCs) were volunteers recruited from the community. Under approval by the institutional review board at UCLA, 41 participants (patients with bvFTD, N=18; HCs, N=23) were enrolled in this study. Informed consent was obtained from participants and caregivers. Patients with bvFTD met International Consensus Criteria for clinically probable bvFTD (2). Clinical diagnoses of bvFTD were supported by predominant frontal and anterior temporal involvement on MRI and/or fluoro-deoxyglucose positron emission tomography brain scans. Exclusion criteria included the presence of complicating medical or psychiatric illnesses or psychoactive medication.

Procedures

Patients with bvFTD were evaluated with four social and emotional scales. Two of these scales were self-administered in both study groups (bvFTD and HC): the modified UCLA Embarrassability Scale (21) and the Social Norms Questionnaire (SNQ) (22, 23). Two caregiver-administered scales were completed by the caregivers of bvFTD patients: the Social Dysfunction Scale (SDS) (24) and the Scale for Emotional Blunting (SEB) (15).

Self-Administered Scales

1. The UCLA version of the Embarrassability Scale, which was modified from Modigliani’s original scale (21), is a significantly expanded and modernized instrument for contemporary use in the United States. It is a self-administered instrument containing 36 items divided into 18 self-embarrassing situations and 18 items depicting situations that are embarrassing for others (vicarious items). Participants are asked to imagine these situations as vividly as possible and whether the situation would cause the participant embarrassment, including self-consciousness, awkwardness, discomfort, or a sense of social exposure. They are told that some items may involve feeling embarrassed for oneself and that other items may involve feeling embarrassed for someone else. They are then asked to record their level of embarrassment on a 5-point Likert scale, with a score of 1 indicating “I would not feel the least embarrassed: not awkward or uncomfortable at all” and a score of 5 indicating “I would feel strongly embarrassed: extremely self-conscious, awkward, and uncomfortable.” Examples of items of self-embarrassment are as follows: “Suppose you go to pay at a restaurant and find that you did not bring your purse or wallet”; and “Suppose that, while laughing heartily with a group of friends, you pass gas.” Examples of items of vicarious embarrassment are as follows: “Suppose you observe someone go into a bathroom and emerge with toilet paper sticking to his shoes”; and “Suppose you are watching an amateur comedy show and one of the performers is unable to make anyone laugh with her jokes.”

2. The SNQ is a 22-item “yes” or “no” questionnaire administered to participants to detect inappropriate social behavior in hypothetical scenarios (22, 23). The SNQ is recommended as part of the socioemotional evaluation of patients with bvFTD (20). Written instructions are as follows: “The following is a list of behaviors that a person might engage in. Please decide whether or not it would be socially acceptable and appropriate to do these things in the mainstream culture of the United States and answer yes or no to each. Think about these questions as if they were occurring in front of or with a stranger or acquaintance, not a close friend or family member.” For example, “would it be socially acceptable to wear the same shirt twice in two weeks?” A total score is obtained by summing correct items, with higher scores indicating greater knowledge of social norms. There are subscales that measure two types of errors: break errors refer to endorsement of a socially inappropriate behavior (e.g., eating pasta with your fingers) as appropriate, and overadhere errors refer to endorsement of a socially appropriate behavior (e.g., wearing the same shirt twice in two weeks) as inappropriate. Although used successfully to distinguish patients with bvFTD and other patient populations (22, 23), the reliability of the SNQ is not established.

bvFTD Caregiver-Administered Scales

1. The SDS is a 40-item informant-based rating scale previously used to characterize social behavioral disturbances in bvFTD (24). The SDS is completed by a spouse, family member, caregiver, or other informant who knows the patient well. The scale originates from the Social Competency Questionnaire, a measure of adaptive social behaviors, with modifications for use with patients with bvFTD. Written instructions are as follows: “For each item, base ratings on a comparison with typical behavior before disease symptoms emerged.” Informants rate items regarding the patient’s social behavior on a 5-point Likert scale (1=very inaccurate, 2=somewhat inaccurate, 3=neither accurate nor inaccurate, 4=somewhat accurate, 5=very accurate). One example of a questionnaire item is as follows: “Makes inappropriate comments to others.” The 40 items are summed, yielding a total raw score, with higher scores suggestive of greater social dysfunction. Previous work has shown high internal consistency and reliability for the SDS (Cronbach’s α=0.977) (24).

2. Caregivers complete the SEB, an instrument used successfully to evaluate patients with bvFTD (25). This scale queries domains such as absence of pleasure-seeking behavior (behavior), affective blunting (affect), and cognitive blunting (thought). Each behavioral symptom is rated by indicating the following: “condition absent” (0 points), “slightly present or doubtful” (1 point), or “clearly present” (2 points). The behavior subscale items include symptoms akin to reclusivity or avoiding social contact. The affect domain involves behaviors such as lacking warmth or empathy. The thought subscale includes items regarding lacking plans, ambition, desires, or drive. The interrater reliability coefficient for this instrument has been robust in previous investigations (α=0.91) (15).

Disease Severity

Disease severity of patients with bvFTD was assessed with confirmation of disease duration and by using the Mini-Mental State Examination (MMSE) (26), the Montreal Cognitive Assessment (MoCA) (27), and the Functional Assessment Questionnaire (FAQ) (28).

Statistical Analysis

Statistical analysis was conducted with SPSS version 25.0. Demographic, descriptive characteristics were generated for both study groups (bvFTD and HC) and compared by using chi-square and t tests for categorical and continuous variables, respectively. The null hypothesis that data for the two major scales (Embarrassability Scale and SNQ) were normally distributed was rejected when testing for distribution of data with the Shapiro-Wilk test. Mann-Whitney U tests were subsequently used for comparison of means between the two study groups. Wilcoxon signed-rank test was used for within-group evaluation of embarrassability subscale scores. Across both groups, Spearman’s rank-order correlations were computed to examine the relationship between the two self-administered behavioral scales.

Results

Participant Characteristics

There were no significant group differences on age, sex, or years of education (Table 1). Patients with bvFTD were, on average, about 4 years into their disease from the time of the first-onset of symptoms and had MMSE and MoCA scores in the mild range, despite moderate functional impairment on the FAQ. Patients’ level of cognitive impairment did not preclude understanding and completion of the self-administered scales.

Behavioral Assessments

Caregiver-administered scales.

The bvFTD group, compared with previously reported norms (15, 24), exhibited social dysfunction and emotional blunting on the SDS and SEB, respectively (Table 1).

Self-administered scales.

Patients with bvFTD did not differ significantly from HCs on the Embarrassability Scale total score (Table 2). On the subscale measures, there were no group differences in self-embarrassment; however, bvFTD patients endorsed greater vicarious embarrassment (p=0.032) compared with HCs. In the bvFTD group, patients did not report significantly greater embarrassability for items involving self versus others, yet the HC group had significantly more self, than other, embarrassment (p<0.001).

Norm, break, and overadherence errors.

Patients with bvFTD had more social norm errors compared with HCs on the SNQ (p<0.001). On the subscale measures, there were no group differences in SNQ break errors; however, bvFTD patients made more overadherence errors on the SNQ (p<0.001) compared with HCs. Correlational analysis showed significant Spearman’s rho correlations between the total Embarrassability Scale score and SNQ overadherence errors (p<0.05); correlations fell just short of significance between vicarious embarrassment and overadherence errors (p=0.056) (Table 3).

Discussion

Decreased ability to be embarrassed may underlie many of the social behavioral disturbances among patients with bvFTD, and an assessment of their awareness of embarrassment could aid in early recognition of this disorder. We investigated self-reports of embarrassment among patients with bvFTD compared with HCs. Patients did not differ from HCs on the total Embarrassability Scale score or on embarrassing items involving themselves; however, compared with HCs, patients reported experiencing significantly greater embarrassment for items involving embarrassing situations for others (vicarious). In comparison, caregivers rated bvFTD patients as having social dysfunction and emotional blunting, and the patients rated themselves worse than HCs in responding to social norms. Finally, results from the Embarrassment Scale correlated with overadherence to social norms. Together, these findings suggest that among patients with bvFTD, increased endorsement of vicarious embarrassment may reflect an inability to take another’s perspective, resulting in rule-based responses regarding levels of embarrassment.

Social emotions, such as embarrassment, are distinct from basic emotions (5); in particular, they require the ability to view oneself and others from the perspective of others (29–31). Self-embarrassment involves self-appraisal of adherence to social norms as seen by others, prompting corrective or reparative actions when necessary (5, 32–42). However, embarrassment can also be a vicarious experience when perceiving the embarrassing actions or mistakes of others (6, 43). In observing someone else violating social norms with potential for social disapproval (44), people imagine themselves from the other’s perspective. Vicarious embarrassment, or fremdscham, is distinct from emotional contagion because it does not require observing the other person’s emotional reaction or even the presence of third parties (43). Both forms of embarrassment rely on taking the perspective of others, an aspect of theory of mind, and assessing violations of social norm rules.

Self-conscious emotions, such as embarrassment, involve the frontal, temporal and limbic areas affected by bvFTD (36, 41, 42, 45–48). Frontopolar, ventromedial frontal, and basal forebrain regions are involved in prosocial sentiments such as embarrassment (47). In an embarrassing task in which bvFTD patients watched themselves singing karaoke, there was decreased physiological and behavioral reactivity associated with smaller right pregenual anterior cingulate cortex gray matter volumes (49). Situations that trigger vicarious embarrassment involve brain areas associated with pain (either physical or social), such as the anterior cingulate cortex and the left anterior insula (43, 50). These are areas affected early in the course of bvFTD.

Given the lack of self-conscious emotions and actual feelings of embarrassment in bvFTD, it is noteworthy that these patients report more vicarious embarrassment than HCs. There appear to be several reasons for this. First, patients with bvFTD have deficits in mentalization or theory of mind, the basic yardstick for taking the perspective of others (18). Hence, their perspective is from their own point of view. Second, the claim of increased embarrassment is associated with overadherence errors to social norms. Increased overadherence errors in bvFTD correlate with difficulty recognizing the changing context of a rule (22), and bvFTD facilitates rule-based and utilitarian judgments on the basis of previously learned social rules (51, 52). Consequently, even in reporting self-embarrassment, patients with bvFTD may be responding less to actual social discomfort and more to what they perceive as an expected level of embarrassment. They may be applying the same predetermined rule for the level of self-embarrassment per social norm violation to the reporting of embarrassment for others.

There are several alternative, but less plausible, explanations for the results in the present study. The patients with bvFTD could have had a truly increased sense of vicarious embarrassment. This interpretation, however, is inconsistent with the vast body of research on socioemotional impairments in bvFTD (3, 4, 7, 13, 15), including the basic diagnostic criteria of loss of empathy or sympathy (2). A second consideration is that for vicarious items, bvFTD patients reported the perceived embarrassment or social discomfort of others rather than their own. However, this seems very unlikely given the clear task instructions and vicarious reports, as well as the impaired mentalization and perspective taking among patients with bvFTD (17–19). Another consideration is that in this study, we could not entirely exclude an effect on the results from the limited, established reliability and other psychometric aspects of the Embarrassability Scale and other measures.

There are several limitations to this study that could be addressed in future investigations. First, there is the consideration of the small number of study subjects, especially in the bvFTD group. The number of participants was sufficient to disclose group differences on some scales but not on others. Second, it would have been beneficial to include a direct measure of mentalization or theory of mind. Third, it would also have been advantageous to have had autonomic measures for assessing a physiological reaction of embarrassment. Fourth, the modified Embarrassability Scale has not been broadly validated in a large population. Finally, other control groups, such as patients with Alzheimer’s disease, were not included.

Conclusions

These results show that patients with bvFTD, despite known impairment in experiencing embarrassment, report significantly more vicarious embarrassment compared with normal control subjects, and this vicarious embarrassment appears to be associated with overadherence to social norms. In addition, these results suggest a self-centered, rule-based reasoning in response to questions of embarrassment for others. Given the social behavioral changes in patients with bvFTD, and the relative insensitivity of traditional neuropsychological measures for early bvFTD, a self-rating scale of vicarious embarrassment could be useful in the initial recognition of this disorder.