Original Paper

Psychopathology 2001;34:289298

Guilt and Depression: A Cross-Cultural Comparative Study

T. Stompe a G. Ortwein-Swoboda a H.R. Chaudhry b A. Friedmann a T. Wenzel a H. Schanda c
a Psychiatric c High

University Clinic, Vienna, Austria; b Psychiatric University Clinic, Lahore, Pakistan; Security Hospital, Gllersdorf, Austria

Key Words Major depression W Feelings of guilt W Delusions of guilt W Cross-cultural-comparison W Austria W Pakistan

So, our data qualify the exclusivity of the aforementioned two points of view and support the need for a psychopathologically differentiated approach.
Copyright 2002 S. Karger AG, Basel

Abstract Although nearly a century has passed since Kraepelins investigations in Java [Cbl Nervenheilk Psychiatr 1904; 27:468469], one crucial question regarding guilt in the course of depression has still not been decided: Is there a more or less stable connection independent of culture, or is guilt confined to certain civilisations? This study investigated this issue in 100 Pakistani and 100 Austrian outpatients diagnosed with major depression according to DSM-IV by means of standardised instruments (Schedule for Affective Disorders and Schizophrenia-Life Time Version, Hamilton Rating Scale for Depression, 21-item version). The experiences of guilt were subdivided into ethical feelings (ethical anxiety and feelings of guilt) and delusions of guilt. It turned out that ethical feelings could be found in both cultures regardless of age and sex. They seem to be primarily related to the extent of depressive retardation. However, the distribution of the two subsets of ethical feelings was culture dependent. Delusions of guilt were confined to patients of the Austrian sample.

Introduction

The crucial question of whether guilt in depression is culturally determined has still not been decided, although almost a century has passed since the investigations of Kraepelin in Java [1]. Depressive ideas and delusions are limited to a very few themes: guilt, hypochondria, impoverishment [25] and nihilistic and persecutory ideas [6, 7]. Whereas ideas of guilt seem to be frequent in Europe and Northern America, they were almost totally denied by authors like Murphy et al. [8] for Eastern cultures. In large areas of Africa as well, no feelings of guilt were found [911]. The difference was often interpreted as a consequence of socialisation in a culture bearing the JudaicChristian faith [8]. A confirmation of this theory was found in studies showing a decrease in feelings of guilt in the course of the last 100 years, most probably due to the declining importance of religion in Western societies [12 14].

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Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com

2002 S. Karger AG, Basel 02544962/01/03460289$17.50/0 Accessible online at: www.karger.com/journals/psp

Dr. T. Stompe Department of Social Psychiatry, University Hospital for Psychiatry Whringer Grtel 1820 A1090 Vienna (Austria) Tel. +43 1 40400 3514

Table 1. Structure of experiences of guilt

Challenged instances Endangered values

Direction of failure Consequences of failure for environment Consequences of failure for the ego

God, family, fellow employees, party, society, mankind, order respect, care, love, integrity, piety, justice, morality, welfare, honesty, decency, image of oneself action, omission, existence impoverishment, illness, misfortune, death, strife, separation feelings of guilt, impoverishment, illness, expulsion from the community, damnation

However, soon objections were raised and newer findings demanded a more sophisticated approach. El Islam proved that feelings of guilt are frequent in Islamic countries [15]. Wulff [16] and Kimura [17] made similar observations in Vietnam and Japan, respectively. They claimed that, while it was true that feelings of guilt were somewhat rarer in Buddhistic cultures, the main difference lies in the guilt-inspiring instances and in the values regarded as threatened by certain actions or omissions [16, 17]. In a recent investigation, Otote and Ohaeri [18] found a (6.3%) rate of delusions of guilt in a Nigerian sample. The research of the last 30 years, supported by the use of standardised instruments, tended to confirm the results of the phenomenologically oriented or clinical investigations of the first half of the 20th century; while feelings of guilt appeared in the course of depressive disorders in nearly all cultures, they were definitely more frequent in the Western world, whereas hypochondriac ideas were the core ideation of depressives in non-Christian cultures [1826]. Following the definition of the German phenomenological philosopher Max Scheler [27], guilt is a phenomenon constantly accumulating in a person because of evil deeds. The feeling of guilt differs from other feelings in its inner logical relationship to this quality. In our model, guilt is a complex experience with cognitive and affective components (table 1). The experience of guilt occurs only when the individual is impaired by the violation of a value considered as central for personal or cultural reasons. An internalised outer instance or, alternatively, a part of the superego is thereby challenged. Alleged consequences of that misconduct may threaten the individual or the social environment. The real or imaginary injury done to the object and the ideas of guilt associated with it may be the consequence of actions (guilt of actions), omissions (guilt of omissions) or the mere existence and identity of the individual in the sense of an ontological guilt [28, 29]. Guilt in the context of depression can be classified in var-

ious ways, for example by distinguishing between primary and secondary feelings of guilt [30]. Whereas primary feelings of guilt cannot be further explained, secondary ones can be deduced from the patients hierarchy of values. For the purpose of our study, we settled on a different model of assignment. Following Kuhs [6], we differentiated guilt in a first step into feelings and delusions of guilt. In normal life, guilt is a subjective experience which cannot be shared by anyone else and which permits no discourse with others. As this experience controls self-evidence and self-esteem as well as interactional conduct, it could be called ethical feelings. They can be defined as the painful experience of reproach (by the self and/or by significant others) for having failed in the face of the challenges of mandatory values. We distinguish three kinds of ethical feelings, namely ethical anxiety, feelings of guilt and feelings of shame. These phenomena are always upheld by an extraordinary conviction and a subjective certainty, even in non-pathological conditions. However, apart from this kind of affective condition, other aspects of inner life can be present with a variable degree of certainty. The so-called Jaspers criteria are also applicable to this kind of guilt. One should nevertheless bear in mind that Jaspers [31] himself said about his definition that the term delusion is applied to all false judgements that share the following external characteristics to a marked, though undefined, degree: (1) they are held with an extraordinary conviction, with an incomparable subjective certainty; (2) there is an imperviousness to other experiences and to compelling counter-arguments; (3) the content is impossible. This clearly indicates that Jaspers did not want to offer a conceptual definition, but describes peripheral attributes. The fact that Jaspers conceived depressive delusions as delusion-like ideas and not as clear-cut delusions is an interesting problem in the history of psychopathology, but too complex to be discussed here. To contribute to the discussion concerning the question of the existence of guilt in Eastern cultures, we inves-

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tigated feelings and delusions of guilt in major depression in Austria, an industrial country with a Christian majority, and in Pakistan, a developing country with a long Islamic tradition. The study was carried out with patients of the Psychiatric University Hospitals in Vienna and Lahore.

Table 2. Sex, age, marital status and years of education of depressive

patients in Austria (n = 100) and Pakistan (n = 100) Austria Sex (M/F) Age, years Years of education Marital status Married Unmarried Divorced Widowed 30/70 52.4B14.9 10.3B3.6 65 13 14 8 Pakistan 49/51 47.9B10.3 8.5B2.8 87 4 1 8

Patients and Methods

Sample Patients of the out-patient departments of both centres diagnosed with depression were interviewed at the second contact (on average 7 days after the first contact) using the Schedule for Affective Disorders and Schizophrenia-Life Time Version (SADS-L) [32]. In the first 100 patients fulfilling the criteria of a major depression according to DSM-IV [33], the existence and severity of depressive symptoms were scored by means of the Hamilton Rating Scale for Depression (HRSD), 21-item version [34, 35]. Both the Austrian and Pakistani authors have often used these instruments in their research work. The Pakistani author (H.R.C.) spent several years as a clinician at the Vienna Psychiatric University Hospital and participated in several studies. Conceptualisation of Experiences of Guilt Ethical feelings correspond to the HRDS levels 1 and 2 (ethical anxiety: HRSD guilt = 1; feelings of guilt: HRSD guilt = 2). Delusions of guilt correspond to the HRSD levels 3 and 4 and were additionally defined with regard to their content: (1) regression into the past previous actions in no direct relation with the present situation are experienced as burdened with guilt; (2) self-accusations in complete contradiction to the patients reality; (3) the experience of guilt may refer to occasions which, objectively seen, are mere trifles; (4) predominance of ontological ideas of guilt over guilt of action or guilt of omission (see above) these patients may exhibit symptoms that we call ideas of grandeur guilt, for example I am the worst human being in the world; (5) hallucinations which coincide with the prevalent mood and thus seem to confirm the delusions of guilt, usually by hearing accusing voices. Statistical Methods We tested the difference between the Austrian and the Pakistani sample by means of t tests. For further analyses, the following four groups were composed: no guilt (HRSD item guilt: 0), ethical anxiety (HRSD item guilt: 1), feelings of guilt (HRSD item guilt: 2) and delusions of guilt (HRSD item guilt: 34). In order to investigate a possible connection between culture and these four levels, 2 tests were computed. In a second step, logistic regressions were carried out. By means of logistic regression, the dependence of a dichotomous variable on other independent variables with arbitrary scale levels can be scrutinised, which is why this method is particularly useful for our problem. All analyses were carried out with SPSS PC (version 6.1).

Results

100 Austrian (30 male, 70 female) and 100 Pakistani (49 male, 51 female) patients who met the criteria of major depression (DSM-IV, SADS-L) were included in our study. Table 2 shows quite distinct differences in the composition of the two samples. The Pakistanis had a lower average educational level, but were much more frequently married than the Austrians, in accordance with the cultural standards of Pakistan, where nearly every adult is married [36]. General Differences in Depressive Symptoms Table 3 presents single HRSD items and the total score. Depressed patients from Vienna were more likely to display depressed mood, guilt, suicidal tendencies, problems with work and activity, insomnia and middle and diurnal variation. Depressed patients from Lahore were significantly more likely to display psychic and somatic anxiety, hypochondriasis and somatic symptoms like gastrointestinal (loss of appetite or constipation) or general somatic symptoms (fatigue, loss of energy), loss of insight, depersonalisation and paranoid and obsessional symptoms. The Austrians more frequently exhibited clusters of symptoms which German-speaking psychiatry in particular describes as endogenous depression. Only 3 Austrian patients had hypochondriac delusions (hypochondriasis = 4). Delusions of persecution (paranoid symptoms = 3 or 4) were absent in both samples. Distribution of Guilt Ethical feelings were found in both countries to the same extent (table 4). However, Pakistanis were usually only subject to mild self-reproach (ethical anxiety HRSD item guilt: 1), while Austrians more often complained of severe feelings of guilt (HRSD item guilt: 2).

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Table 3. Comparison of HRSD items between Vienna and Lahore for all inclusion cases (using t test)

HRSD item

Vienna (n = 100) mean SD 0.87 0.96 1.10 0.87 0.76 0.84 1.02 1.04 0.96 1.33 1.01 0.69 0.67 0.80 1.01 0.37 0.77 0.86 0.49 0.31 0.54 5.39

Lahore (n = 100) mean 2.31 0.74 0.92 1.45 0.80 1.04 2.38 0.90 0.79 2.10 2.76 1.30 1.99 0.96 2.08 0.76 0.60 0.76 0.46 0.85 0.04 24.23 SD 0.60 0.69 0.80 0.54 0.59 0.65 0.63 0.78 0.74 0.70 0.85 0.56 0.61 0.65 0.63 0.43 0.60 0.43 0.52 0.36 0.14 5.01

Significance

Depressed mood Guilt Suicide Insomnia, early Insomnia, middle Insomnia, late Work/activities Retardation Agitation Anxiety, psychic Anxiety, somatic Somatic symptoms, gastrointestinal Somatic symptoms, general Genital symptoms Hypochondriasis Insight Loss of weight Depersonalisation Paranoid symptoms Obsessional symptoms Diurnal variation Total score

2.90 1.21 1.35 1.12 1.36 0.92 2.82 1.12 0.70 1.72 1.07 0.97 1.29 1.17 0.68 0.11 0.53 0.38 0.13 0.09 0.66 22.45

0.000 0.000 0.002 0.001 0.000 0.259 0.000 0.093 0.459 0.012 0.000 0.000 0.000 0.044 0.000 0.000 0.476 0.000 0.000 0.000 0.000 0.016

Table 4. Guilt in major depression in Austria and Pakistan

Table 5. Logistic regression models for the target symptoms ethical feelings and delusions of guilt

Austria Pakistan 2 (n = 100) (n = 100) Ethical feelings (guilt = 1 + 2) Ethical anxiety (guilt = 1) Feelings of guilt (guilt = 2) Delusions of guilt (guilt = 3 + 4) 63 32 31 9 60 46 14 0.19 4.12 8.29 9.42

Significance Target symptoms 0.663 0.042 0.004 0.002 * p ! 0.05, ** p ! 0.01. B = Regression weight; SE = standard error of regression weight. Ethical feelings Delusions of guilt Variables in the equation retardation suicidal tendencies depersonalization country B 0.805 0.470 0.746 9.390 SE 0.22** 0.17* 0.32* 0.79

Delusions of guilt, on the other hand, were found exclusively in the Viennese sample (9%). This frequency corresponds roughly to numbers found in the German samples of Kuhs [6] (11.9%) and Tlle [37] (12.6%). Dependence of Guilt on Psychopathology and Biological and Socio-Cultural Variables Comparing patients with and without ethical feelings, logistic regression showed that the existence of ethical

feelings depended mainly on the degree of severity of the depressive retardation (table 5). Suicidal tendencies, more frequently found in patients suffering from ethical feelings, seem to correspond with the degree of severity of depression. It is understandable without further explanations and also supported by earlier studies that suicidal tendencies coincide with feelings of guilt [38]. Comparing patients with feelings and delusions of guilt, table 5 reveals the decisive influence of culture. In addition, there is

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a relationship between delusions of guilt and depersonalisation. Neither age nor sex have any influence on the existence of ideas of guilt.

Discussion

As guilt in general (table 1) can be subdivided into several components, we wanted to investigate their distribution in two different cultures. Guilt depends on cognitive and affective preconditions as well as on the cultural framework. Both feelings and delusions of guilt stem from the non-fulfilment of ethical challenges and are subject to biological, socio-cultural and situational influences. First, a moral judgement on the ethical quality of such challenges to action is formed at the cognitive level. After deciding that this challenge to action is correct and justified, the individual has to find out whether he/she feels responsible for the implementation. Under certain conditions, motives such as convenience, timidity, ego weakness or incompatibility with other values may cause reprehensible actions or omissions. If, however, culturally or individually determined central values are being challenged, conscience may be activated. In such a case, personal responsibility may be reconsidered, and if action still does not take place, ethical feelings and remorse are likely to arise. The process of decision making and the kind of ethical feeling released are determined by moral judgement, judgement of responsibility, conduct-regulating systems and religions and philosophical-ethical views of life. Ethical Feelings In conflict-burdened situations, when personally or culturally important values are violated, the appeal to internalised instances triggers different ethical feelings. By values we understand affect-laden contents which represent what is important to an individual, what he/she respects or reveres, but also what he/she fears or hates and what is always apt to provide him/her with goals, scopes and directions. Ethical anxiety is the oldest feeling released by any violation of values. This feeling has its origin in an archaic knowledge about revenge for incorrect conduct [39, 40]. In its indifferent quality and its lack of an object, ethical anxiety is more basic than its descendants, feelings of guilt and shame. In its lack of an object, it corresponds to the emotional state which Berrios et al. [41] described as affective guilt. Ethical anxiety may well have its roots in the biological sphere. Anxiety, which is automatically trig-

gered by real or imagined deviations from group standards, raises the fitness of the group as a whole and is consequently a selective advantage. Remorseless breakers of rules are more likely to be killed or ousted by the other members of the group [39]. Ethical anxiety prevails as long as internal conflicts between morality and other conflicts remain unconscious. The tolerance of vague anxieties without definite cognitions depends on culture and personality. Usually, a transition takes place towards cognitive/affective complexes, namely feelings of guilt and shame. If these conflicts are conscious, feelings of guilt and shame develop without the intermediate stage of ethical anxiety. Feelings of guilt and shame require the following prerequisites: the existence of a violated value and of accusing personal instances. With the transition from ethical anxiety to feelings of guilt, the fear of spiritual death dissociates itself from fear of physical suffering [42]. Feelings of shame occupy an intermediate position. While ethical anxiety is a rather unspecific affect indicating misconduct, feelings of guilt and shame are complex affects. Whereas, according to psychoanalytic theory, feelings of guilt should protect others, feelings of shame preserve the integrity of the individual [42]. Shame replaces the fear of outer punishment by self-humiliation and selfcontempt. While feelings of guilt primarily refer to an inner instance called the conscience or superego, feelings of shame refer to both an inner and an outer instance. Feelings of shame arise on the one hand through the contemptuous glance of fellow members in a social environment and on the other hand through the confrontation of personal conduct with the principles of the ideal ego [43, 44]. This interaction of inner and outer instances is part of the phenomenology and psychopathology of shame. While feelings of guilt are indicative of the evil that has accumulated within an individual, feelings of shame give evidence of weakness and loss of control. According to Benedict [45], feelings of guilt and shame are higher emotions which make a decisive contribution to the protection of a societys central values. Since cultures prefer to emphasise one of the two higher emotions to regulate the conduct of its members, Benedict [45] distinguishes between shame and guilt cultures. The main difference probably lies in the central values of a culture and how their violation encourages the formation of shame or guilt [36, 46]. On the one hand, there are values primarily regulated by feelings of guilt (religious offences), where God is the ultimate authority. On the other hand, there are also values which in all cultures mainly provoke feelings of shame (e.g. loss of control over excretions).

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In Pakistan, the central values are honour, dignity, pride, virility and family ties (table 2). An omission or an action against these values triggers primarily feelings of shame. Respect is protected by the risk of becoming a ridiculous figure and an object of contempt for others [36]. Relatives who serve as a strong instance of control are of great importance for the socialisation of an individual in the context of a shame culture. This means that the child has to take over a certain social role attributed to him/her rather early in life. The central European educational ideal is directed towards such values as self-reliance, selfdetermination, achievement, utility, personal ambition, thrift, individuality and personal responsibility. Some of these values constitute a kind of symbolic capital [47] and are as such also regulated by feelings of shame. Other values, especially personal responsibility, are regulated by feelings of guilt. In every culture, both feelings are present and serve as censors of conduct. Moral Judgement Cognition motivates human beings to act in accordance with their moral definitions. In moral judgements, this knowledge is applied to past, present and future situations. According to Piaget [48], Rest [49] and Kohlberg [50], the development of moral judgement follows a precise sequence of distinct stages. Each stage represents a certain organisation of mental faculties for perceiving and judging socio-moral environments. Kohlberg [50] postulated three levels (pre-conventional, conventional and post-conventional). The structure of a moral judgement is independent of its content. These stages of development are noteworthy for their cross-cultural invariability. The level reached by an average adult in a given culture depends on the specific conditions of motivation existing in this culture [51]. The levels of moral judgement represented in a certain culture are both sufficient and adequate for the solution of conflicts which arise. As Snarey [52] exposed in a review, studies on the level of moral judgement in several countries of the Third World testify to a very low level of principle-orientated, post-conventional reasoning. In an investigation of the development of moral judgement in Pakistani adolescents, Masqud [53] demonstrated that the pre-conventional structural level was predominant. In contrast, Austrians, like the members of most industrialised Western societies, act on a conventional level [51]. These findings are important in the context of our investigation, since there is a strong connection between the structural level of moral judgement, the assessment of responsibility and the direction of action [54]. The higher the structural level of moral judge-

ment, the more frequently cognitions and actions correspond. A discrepancy between judgement and action therefore triggers strong feelings of guilt. The Judgement of Responsibility and the Historical Process of Individualisation Inserted between the moral judgement and the action is the question of perceived responsibility to transform cognition into activity. In traditional cultures, responsibility often lies either with the head of the family or with the family as a collective. Western culture and some cultural areas in East Asia influenced by Confucianism have gone through a process of individualisation. From the European Middle Ages onwards, a process of steadily increasing individualisation took place, which found its culmination in the beginning of the 19th century [55]. This process was closely linked to the transformation of a shame culture into a guilt culture. The gradual elaboration of differentiated concepts of sin, guilt, remorse and penitence in this process was of crucial importance [56, 57]. In contrast, in Pakistan, less emphasis is placed on the development of the individual personality. Hierarchies within the family are respected and taken for granted [36]. The personal acceptance of responsibility for actions or omissions is also closely related to the notion of free will and self-determination. In contrast to Catholicism, Sunnite Islam incorporates beliefs of predestination. The notion of kismet is important for the attitude towards personal guilt in popular Islam. While the Koran itself offers no definite view as to predestination, but only various, potentially contradictory statements, popular Islam preaches the believers submission and surrender to a destiny preordained by God; whether for the better or for the worse, all events and phenomena are subject to Allahs will. This attitude leaves only limited scope to the recognition of free will, the acceptance of personal responsibility or a feeling of individual guilt. In a transcultural study, Rder et al. [58] found that Egyptians more often felt dependent on fate or on the immediate social environment than Germans. If responsibility for the execution of moral judgements is not centred on the individual, no cognitive dissonance arises, which is the prerequisite for the development of feelings of guilt. Conduct-Determining Regulatory Systems According to the anthropologist Clifford Geertz [59], culture can be defined as a system of control mechanisms, plans, rules and instructions which regulate conduct. Conduct-determining regulatory systems refer to consequences of actions for other persons, groups or social prin-

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ciples, both negative ones that should be avoided and positive ones that should be achieved. According to the German sociologist Simmel [60], societies attain the respect of standards and values by three different disciplinary systems: (1) a legel code, (2) a moral code and (3) an honorary code. These codes are meant to achieve standardisation and to make individual conduct more predictable [61]. The techniques of the three systems differ markedly from each other. Each of them refers to a central outer instance and simultaneously appeals to an inner one. The central outer authority of the legal system is the legislator, but it is difficult to determine a real inner instance. As soon as laws are internalised, we find an additional emergence of demands triggered by morality or honour. The feeling caused by a breach of law is primarily fear of punishment. Even if the acting persons are not conscious of it, the ultimate outer authority of any moral system is God, although the values originally instituted by religion may have become secularised. The most important outer instances of a code of honour in traditional societies are the family and the immediate social environment. They appeal to the ego ideal as the inner authority. An infringement upon honour triggers feelings of shame. Where laws affect outer purposes by outer means and ethics inner morality by inner means, the code of honour maintains an intermediate position between the two by achieving outer purposes by inner means. According to a legal code, the major orientation lies in the polarity obedience-disobedience, while the polarity of the moral code is good-evil. The semantics of honour secure their validity using the antagonism of shame-honour. It motivates individuals to obey the norm; transgressions cause feelings of shame through the activation of inner and outer instances. All known societies of the past and the present have always employed all three systems to different degrees to regulate conduct. In family-oriented and rank-oriented societies with low social mobility like Pakistan [36], correct conduct is rather achieved by the system of honour than by the moral system [62]. In contrast, Western societies in the two centuries following the onset of the industrial revolution developed from static societies with rigid images of social roles first into socially stratified class societies and then into functionally differentiated modern societies with social mobility, where the individual is to a certain extent free to choose his social environment and the only limitation is education [63]. In this situation, conduct is regulated to a far greater extent by the legal and moral system than in traditional societies like Pakistan. However, this discrepancy is by no means absolute or exclusive. As Vogt [64]

demonstrates, honour is still an important value also in Western societies and hence serves the regulation of conduct; on the other hand, moral systems can also be found in traditional cultures. Religious Aspects of Sin and Guilt We maintained that God is the last instance of a moral system based on guilt. When we have to consider this instance as a central part of value systems [5], our reasoning is in danger of becoming self-contradictory, since religion certainly has a higher ranking in Pakistan than in Austria. The solution to this apparent dilemma is the realisation that Islam offers a notion of sin quite different from the Christian tradition. The Koran holds that man is able to distinguish between good and evil and to modify his conduct accordingly. In Islam, sin originates from insinuations by Satan; it is a temptation approaching man from outside. If he but takes refuge with Allah, he can resist Satan and is free to opt for the good [65, 66]. God imposes visitations on man, but Allah is also the Merciful who will not burden man with unbearable loads. In his utterly absolute position, Allah is not really concerned by the sins of man; man sins not against Allah but against himself. Islam recognises three categories of sin [65, 66]: (1) unbelief as the utmost sin it may take the form of nonrecognition of God, polytheism or apostasy from true faith; (2) mortal sins such as rebellion against parents, murder, perjury, adultery, homosexuality, the consumption of wine, and (3) lesser offences such as lying. According to Islamic belief, everyone who conforms to the main doctrines and does not commit one of the three forms of unbelief shall ultimately be saved, although he probably might have to endure hell-fire for a limited period before finally gaining access to paradise. Allah forgives all sins of man, great and small ones, for his mercy is boundless (Koran 7,156). Christianity, in contrast, regards sin as a personal offence against God [67, 68]. Sin is resistance to God in his task of salvation, redemption and creation; therefore, it is an act of aggression against God, man and the world. The outer deed reveals the inner personality; it is an indication of a moral attitude. St. John already identified sin as a condition of man and mankind. The New Testament differentiates between three categories of sin: (1) sins indicative of a way of life that bars access to the Kingdom of Heaven (1. Kor. 6,9; Gal. 5,19); (2) sins indicative of induration of the heart mortal sins according to St. John (1. Joh. 5,16), and (3) sins generated by everyday life (Joh. 3,2).

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Christianity has throughout its history always been obsessed by the fear that even the majority of its believers may ultimately be destined for hell [69]. Existence of Ethical Feelings with Different Distribution of Subtypes in Both Cultures Apart from differences in a number of HRSD items between Austrian and Pakistani patients (table 1), delusions of guilt seem to be a culture-bound phenomenon. Our data suggest that the existence of ethical feelings is related to the severity of depressive retardation (table 5). Ethical feelings usually originate from inconsistencies in the transformation of judgements of responsibility into activities. Drive is activated by a voluntary act and transformed into a meaningful action. The crucial element is that a sound person retrospectively or prospectively recognises a situation where he is free to opt for one or to choose between several real alternatives, whereas this possibility of free choice is substantially reduced in depressives. It depends on the conditions of socialisation and the dominating regulatory system of a certain culture, which of the three ethical feelings described by us (ethical anxiety, feelings of guilt and shame) is actually experienced. With the deepening of depression and the retardation of drive, the afflicted person falls more and more behind the achievement of internalised values and standards. According to Tellenbach [70], this constellation, which he called Remanenz (remanence), is the typical basis for the development of depressive feelings of guilt. These feelings thus originate from a misinterpretation by which not being able to becomes not wanting sufficiently, burdened with guilt. The main difference between the feelings of guilt in sound and depressive persons lies in this constellation. However, the more values are regulated by codes of honour, the less frequently feelings of guilt will develop in the course of depression. We think that on the first level of the item guilt, a precise differentiation between feelings of guilt and shame is not possible. In order to distinguish it conceptually from feelings of guilt, we have called this emotional condition ethical anxiety. As table 4 indicates, ethical feelings (ethical anxiety, feelings of guilt) were recognisable in depressive patients in both countries. Differences emerge when one takes notice of the distribution of the two forms considered in our study. While there was no difference regarding the existence of ethical feelings between the two samples, 46% of Pakistanis presented ethical anxiety (guilt = 1) and only 14% feelings of guilt (guilt = 2) with definable contents. By contrast, 31% of the Austrians had definite feelings of guilt. If it is true that

ethical anxiety and feelings of guilt constitute two discernible phenomena which moreover tend to develop differently in different cultural backgrounds, it follows that the alleged universality of guilt in general will have to be reexamined. While, according to our data, ethical feelings could be found more or less equally in our two samples, the distribution of the sub-sets of ethical feelings seems to be largely culture dependent. Existence of Depressive Delusions of Guilt Only in Austria Feelings of guilt which are not accessible to repentance lead to ontological guilt. In delusions of guilt, the affective-cognitive coherence characterising feelings of guilt is lost. The specifically Western process of individualisation encourages the emergence of a certain type of personality which is characterised by a strong sense of responsibility and the rigid assumption of social rules [71]. This particular personality was named typus melancholicus by Tellenbach [70]. Its core features are orderliness and conscientiousness. Orderliness embodies the active, agreement-achieving side of typus melancholicus, conscientiousness the passive, guilt-avoiding side [7274]. Thus, one of the central qualities of the typus melancholicus is the hasty responsiveness of conscience even in sound conditions. Those people are characterised by high moral sensitivity. They consider situations and conflicts as ethically relevant which are perceived as neutral by the majority. A pronounced orientation towards prescribed norms entails an over-sensitivity of conscience, which provokes guilt even in minor offences. The typus melancholicus is most frequent in cultures emphasising personal responsibility. Apart from the Christian Occident, this kind of personality is also considerably important in Japan [75, 76], where the ethics of Confucianism [77] seem to influence the conditions of socialisation in a way comparable to the position of Calvinism [62] and Catholicism [56] in Europe. The finding that delusions of guilt are quite frequent in depression also in Japan [76] seem to underline a certain affinity between typus melancholicus and delusions of guilt. In depression, the connection between misconduct and resultant guilt is increasingly lost, and finally the person is guilty regardless of concrete actions or omissions, i.e. the transfer from feelings to delusions of guilt is achieved. However, aside from cultural reasons for the different distribution of delusions of guilt, one also has to consider the possibility that delusional and non-delusional depression are two distinct diseases [7881]. Despite the fact that the 21-item HRSD is an established instrument also in transcultural studies on depres-

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sion [22, 8284], our paper points to demands for adaptations to improve its applicability in such investigations: (1) for the assessment of the whole spectrum of ethical feelings, the HRSD needs an additional item for shame; (2) the definitions of feelings and delusions of guilt are lacking in (psychopathological) precision, and (3) the

same holds good for the differentiation between hypochondriac anxiety and delusions. Moreover, proper ethnolinguistic studies could provide the basis for the development of special instruments for transcultural studies beyond the HRSD.

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