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. Author manuscript; available in PMC: 2024 Oct 1.
Published in final edited form as: J Interpers Violence. 2023 Jun 29;38(19-20):11117–11137. doi: 10.1177/08862605231179721

Trauma-Related Shame and Guilt as Prospective Predictors of Daily Mental Contamination and PTSD Symptoms in Survivors of Sexual Trauma

Jesse P McCann 1, Jordyn M Tipsword 1, C Alex Brake 2, Christal L Badour 1
PMCID: PMC10602615  NIHMSID: NIHMS1935026  PMID: 37386852

Abstract

Background:

Mental contamination (MC), the experience of dirtiness in the absence of a physical contaminant, has established links with posttraumatic stress disorder (PTSD). Shame and guilt have well-documented relationships with symptoms of PTSD and may play a role in the development and maintenance of MC. The present study examined whether trauma-related shame and guilt prospectively predicted daily MC and symptoms of PTSD among 41 women with a history of sexual trauma.

Method:

Women completed baseline and twice-daily assessments of MC and symptoms of PTSD over a two-week period and baseline measures of trauma-related shame and guilt. Two sets of hierarchical mixed linear regression models examined individual and combined fixed effects of baseline trauma-related guilt (guilt cognitions and global guilt) and shame in predicting daily trauma-related MC and symptoms of PTSD.

Results:

Trauma-related shame positively predicted both daily MC and PTSD. This association remained robust even when accounting for the experience of trauma-related guilt. Neither trauma-related guilt cognitions nor global guilt predicted daily MC or PTSD.

Conclusions:

While other studies have addressed shame related to sexual assault, this is the first study to demonstrate a positive prospective relationship between shame and trauma-related MC. Findings regarding PTSD and shame are consistent with a growing literature. Further research is needed to better understand the temporal relationships between trauma-related shame, MC, and symptoms of PTSD, including how these variables interact and change over the course of PTSD treatment. A better understanding of the factors influencing the development and maintenance of MC can inform efforts to more easily target and improve MC, and subsequently PTSD.

Keywords: mental contamination, trauma-related shame, trauma-related guilt, PTSD symptoms, daily monitoring design

Mental contamination (MC) – the experience of dirtiness in the absence of a physical contaminant (Rachman, 1994) – can be prompted by thoughts, memories, or other non-contact triggers and is often experienced internally (Rachman, 1994, 2004). These triggers are often human- rather than substance- or object-based and are usually linked with violation or immorality (Rachman et al., 2015; Radomsky et al., 2017). While obsessive-compulsive disorder (OCD) has been the primary clinical population of interest in the majority of research studies on mental contamination (Coughtrey et al., 2012), several studies have linked MC to posttraumatic stress disorder (PTSD; Badour, Feldner, Blumenthal, et al., 2013; Fergus & Bardeen, 2016; Olatunji et al., 2008), and the most robust associations emerge following sexual trauma. Approximately 70% of women in a community sample of sexual assault survivors reported experiencing urges to wash immediately following their assault (Fairbrother & Rachman, 2004). Women who reported urges to wash scored significantly higher than those who did not on a measure of MC, and MC scores were positively correlated with PTSD symptoms. Laboratory tasks involving deliberate recollection of sexual trauma memories have also elicited experiences of dirtiness, urges to wash, and washing behaviors (Badour, Feldner, Babson, et al., 2013; Fairbrother & Rachman, 2004). The experience of MC is linked to more severe PTSD as well as an array of negative mental health outcomes (e.g., more frequent risk-taking behaviors, more negative attitudes toward help-seeking, and increased self-harm and suicidality; Brake et al., 2018, 2019). These findings highlight the clinical importance of increasing understanding of MC as it relates to trauma exposure as well as PTSD. In order to learn how to target and improve the deleterious sequelae that can stem from MC, it is crucial to better understand the factors involved in the development and maintenance of MC following trauma.

Research on the development and maintenance of MC has centered around the role of specific emotions. Shame (an emotion characterized by beliefs that one is inadequate, weak, and/or inferior; Tangney & Dearing, 2003) and guilt (an unpleasant sensation coupled with the belief that one should have behaved, felt, or thought differently; Kubany et al., 1995) are two such emotions theorized to be relevant to MC (Rachman et al., 2015). It has been posited that shame may be key to experiences of contamination following sexual trauma (Jung & Steil, 2013; Steil et al., 2011). Studies have also found links between washing behavior and both shame and guilt among non-clinical samples in which MC was experimentally elicited (Radomsky & Elliott, 2009). Individuals experiencing MC often report shame or guilt related to unwanted intrusive thoughts, memories of perceived blameworthy actions, or perceived dirtiness (Rachman et al., 2015). However, only one study has linked negative posttraumatic cognitions involving the self and self-blame – respective cognitive features of trauma-related shame and guilt – and MC among sexual assault survivors (Olatunji et al., 2008). Direct empirical investigation is necessary to substantiate the theoretical effects of shame and guilt on trauma-related MC.

In addition to preliminary relationships with MC, shame and guilt have well-established relationships with PTSD. In one large sample of adults with a history of interpersonal trauma, participants were more than twice as likely to meet criteria for PTSD if they reported ongoing shame and 62% of individuals with PTSD endorsed ongoing shame (Badour et al., 2017). Other studies have found that shame positively predicted severity of PTSD symptoms (e.g., Øktedalen et al., 2015), and increased shame has been linked to increased PTSD symptoms before and after PTSD treatment and at follow-up (van Minnen et al., 2002). Changes in shame have also prospectively predicted changes in PTSD symptoms during treatment, but not the reverse (Øktedalen et al., 2015), suggesting that shame may be a crucial mechanism of change in treatments for PTSD. Additionally, guilt, which often co-occurs with shame, may maintain PTSD symptoms by promoting avoidance coping that precludes emotional processing of fear (Street et al., 2005). Similar to shame, reductions in guilt during PTSD treatment have been linked to subsequent reductions in symptoms of PTSD (Allard et al., 2018, 2021). However, some research has found that trauma-related guilt may persist even after successful amelioration of PTSD symptoms during treatment (Larsen et al., 2019). Interventions specifically targeting these emotions (e.g., trauma-informed guilt reduction therapy) have been tested in recent years and have evidenced both reductions in guilt and shame as well as PTSD symptoms (Norman et al., 2022). This research highlights the utility of targeting these emotions in tandem with PTSD.

Despite positive associations between guilt and PTSD, there is robust evidence suggesting that shame may be more maladaptive than guilt (Tangney & Dearing, 2003). Shame is more strongly associated with PTSD symptoms than guilt in female survivors of intimate partner violence (Beck et al., 2011). Furthermore, in studies where both shame and guilt are modelled in predictions of PTSD symptoms, only shame retains its significance (see Pugh et al., 2015 for a review). Indeed, one study found that trauma-related shame accounted for twice the explained variance in PTSD symptoms (65.2%) relative to trauma-related guilt (34.8%; Cunningham et al., 2018). More recently, it has been proposed that shame should be a primary target for preventative intervention at the relational (e.g., postnatal home visitation programs to foster secure child-parent attachment), community (e.g., financing development and healing programs in communities experiencing mass traumatization), institutional (e.g., trauma-informed policing processes) and macrolevel (e.g., legislation targeting economic inequalities that foster feelings of shame) in order to reduce both the risk and prevalence of complex PTSD (Salter & Hall, 2022). Because shame following trauma exposure is a widespread issue, a shame-sensitive framework for use in the health and human services field has also been developed to effectively acknowledge and address the impact of shame on patients (Dolezal & Gibson, 2022).

Taken together, existing literature highlights the importance of shame and guilt in understanding both MC and PTSD. The present study examined whether trauma-related shame and guilt prospectively predicted daily MC and PTSD symptoms among a sample of women with a history of sexual trauma. This study was the first to use a daily monitoring design to specifically examine prospective associations between shame/guilt and either MC or PTSD symptoms. Use of daily assessments in the current study better accounts for fluctuations in MC and PTSD within and across days and therefore allows for a more representative relationship of how MC and PTSD vary day-to-day, which cannot be captured by a single assessment or with traditional longitudinal panel designs. It was hypothesized that higher trauma-related shame and guilt at baseline would prospectively predict higher daily MC across the two-week monitoring period. It was further hypothesized that higher trauma-related shame and guilt at baseline would prospectively predict more severe daily PTSD symptoms. However, it was anticipated that baseline trauma-related guilt would no longer predict greater daily PTSD symptoms when trauma-related shame was included in the model.

Method

Participants

The present study involved secondary data analysis from a parent study investigating the relationship between PTSD symptoms and MC following sexual trauma (Brake et al., 2021). Participants were 51 individuals with a history of sexual trauma and current trauma-related MC. Ten individuals reported no current MC during in-person interviews (described below) and were thus removed. The 41 remaining participants were women who ranged in age from 18 to 57 (Mage = 33.0, SD = 12.4) and endorsed: sexual contact during childhood (56.1%); sexual contact involving actual or threatened force (90.2%); and/or sexual contact while under the influence of substances (58.5%). Participants identified largely as Caucasian (73.2%), with a substantial proportion also identifying as African American (19.5%). Hispanic ethnicity was reported by 9.8% of women. Most women identified as heterosexual (70.7%). Most participants (92.7%) also reported having completed at least some college. Annual income ranged from < $20,000 to greater than $100,000, with the majority of women reporting incomes of less than $20,000 (46.3%). Detailed participant information can be found elsewhere (Brake et al., 2021).

Procedure

The University of Kentucky Nonmedical Institutional Review Board (IRB) approved all procedures and each participant provided informed consent before beginning the study. Individuals were recruited through web-based advertising or flyers in the community. Prospective participants completed an initial phone screen to establish study eligibility followed by a) a series of online questionnaires, b) a laboratory visit that included clinical interviews and self-report assessments, and c) 14 days of twice-daily assessments of MC and PTSD completed via LifeData, a smartphone application. During the laboratory visit, participants downloaded the LifeData app and were trained in use of the app. For the two-week period immediately following the laboratory visit, participants completed twice-daily assessments at 9:00 AM EST and 5:00 PM EST each day. If a given assessment was not completed within four hours, that assessment was skipped. Participants completed 84.8% of all possible assessments (974 out of 1148). The mean number of responses per participant was 23.76 (SD = 5.24, range 7-28), and more than 90% of women completed 15 or more assessments. Additional information can be found in Brake et al. (2021).

Measures

Baseline measures

History of sexual trauma

Sexual trauma history was based on three items from the National Stressful Events Survey (NSES; Kilpatrick et al., 2011), a national survey that assessed the prevalence of exposure to DSM-5 Criterion A traumatic events. Individuals were eligible for enrollment if they endorsed sexual trauma involving 1) childhood sexual contact, 2) force or threat of force, or 3) inability to consent due to the influence of drugs or alcohol.

Mental contamination following sexual trauma

The Posttraumatic Experience of Mental Contamination scale (PEMC; Brake et al., 2019) is a 20-item self-report measure adapted from the Vancouver Obsessional Compulsive Inventory – Mental Contamination scale (VOCI-MC; Radomsky et al., 2014) to evaluate trauma-related MC (e.g., “Since the traumatic event, I often feel dirty inside my body.”; Brake et al., 2019). The PEMC uses a five-point Likert-type scale (0 = Not at all to 4 = Extremely) and participants indicate the extent to which each item is relevant. PEMC items were anchored to participants’ most distressing sexual trauma. An overall severity index for sexual trauma-related MC was computed by summing item scores, with higher scores reflecting greater MC. Participants were eligible for the study if they reported a score of ≥10 on the PEMC, which aligns with scores indicating moderate MC on the VOCI-MC (Coughtrey et al., 2014). Scores on the PEMC demonstrate strong internal consistency, convergent validity with the VOCI-MC, discriminant validity with measures of contact contamination, PTSD symptoms, and depression, and superior utility compared to the VOCI-MC in assessing trauma-related MC (Brake et al., 2019). The PEMC demonstrated excellent reliability in the current study (α = .92). Two items from Fairbrother and Rachman’s (2004) sexual assault-related MC interview were also used to confirm current trauma-related MC during the laboratory visit (“What, if anything brings back that feeling of dirtiness now?”; “What about memories of the unwanted sexual experience, do they bring back that feeling of dirtiness?”). Individuals were ineligible to continue if they responded in the negative to both items.

PTSD symptoms

Baseline PTSD symptoms were assessed using the past-month version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, Schnurr et al., 2013). The CAPS-5 is a semi-structured clinical interview measuring the frequency (number of occurrences or percentage of time in past month) and intensity (minimal to extreme) of all 20 DSM-5 PTSD symptoms. Total PTSD severity scores (0 = Absent to 4 = Extreme/Incapacitating) were determined by summing the frequency/intensity scores for all symptoms, with higher scores indicating more severe symptoms. Scores on CAPS-5 items were also used to determine PTSD diagnostic status (Weathers et al., 2018). The CAPS-5 has demonstrated good convergent validity with other measures of PTSD symptoms and discriminant validity with measures of psychosocial functioning, anxiety, depression, somatization, and alcohol use disorder (Weathers et al., 2018). The CAPS-5 exhibited good internal consistency in the current study (α = .84). Random selection of 20% of interviews indicated excellent interrater reliability regarding diagnostic agreement (κ = 1.0) and agreement on total PTSD symptom severity (average r = .98).

Trauma-related guilt

Guilt linked to sexual trauma was assessed using the Trauma-Related Guilt Inventory (TRGI; Kubany et al., 1996). The TRGI is a 32-item measure using a five-point Likert-type scale, with varying benchmarks depending on the item (e.g., 0 = Extremely true; 4 = Not at all true). The measure has three scales (global guilt, distress, guilt cognitions). Research supports a model of trauma-related guilt comprised of only the global guilt and guilt cognitions scales (Cunningham et al., 2017), arguing that the distress scale reflects broad trauma-related emotional reactivity. Further work has used only the global guilt (e.g., “I experience intense guilt that relates to what happened.”) and guilt cognitions (e.g., “I could have prevented what happened.”) scales due to similarities between the distress scale and measures of PTSD symptoms (Street et al., 2005). Thus, only the TRGI-global guilt and guilt cognitions scales were used to measure trauma-related guilt in the present study and were scored per instructions in Kubany et al. (1996). Scores on these scales have demonstrated high internal consistency, satisfactory temporal stability, and strong convergent validity with other measures of guilt (Kubany et al., 1996). The TRGI-guilt cognitions and global guilt scales exhibited excellent (α = .92) and good (α = .86) internal consistency in the current study, respectively.

Trauma-related shame

Shame related to sexual trauma was assessed using the Trauma-Related Shame Inventory (TRSI; Øktedalen et al., 2014). The TRSI is a 24-item measure that uses a four-point Likert-type scale (0 = Not true of me to 3 = Completely true of me). Scores for each item (e.g., “I am ashamed of myself because of what happened to me.”) were summed to create a total severity rating, with higher scores indicating greater trauma-related shame. The TRSI has demonstrated high internal consistency (e.g., DeCou et al., 2019) and convergent validity with measures of depression and self-judgment and discriminant validity with measures of trauma-related guilt (Øktedalen et al., 2014). The TRSI exhibited excellent internal consistency in the current study (α = .95).

Daily questionnaires

Mental contamination following sexual trauma

Trauma-related MC was reported twice daily using the State Mental Contamination Scale (SMCS; Lorona et al., 2018). The SMCS is a 15-item self-report inventory adapted from the Vancouver Obsessional Compulsive Inventory – Mental Contamination scale (VOCI-MC; Radomsky et al., 2014). While the VOCI-MC assesses trait-level MC, the SMCS surveys state MC by modifying VOCI-MC items to reflect current MC (e.g., “Since the last time I was asked to respond, I felt dirty inside my body.”). Participants rated their agreement with each item using a Likert-type scale (0 = Strongly disagree to 4 = Strongly agree). Daily assessment instructions for the SMCS were modified in the current study to refer to the index trauma reported in the CAPS-5 interview. Individual SMCS items were summed to create a total score at each assessment timepoint, with higher scores indicating higher levels of state MC. The SMCS has demonstrated strong internal consistency and convergent validity in preliminary evaluations of its psychometric properties (Lorona et al., 2018). The SMCS also exhibited excellent reliability in the present study for evaluating between-person differences (Rkf = .99) and within-person change (RC = .95).

PTSD symptoms

Daily PTSD symptoms were surveyed using an adapted version of the PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, Keane et al., 2013), a 20-item self-report inventory that surveys severity and frequency of PTSD symptoms. The adapted version assessed PTSD symptoms experienced since the last daily diary report and is supported by past research adapting the PCL-5 for daily assessments (e.g., Dworkin et al., 2017). At each assessment, participants reported symptoms experienced since the last daily assessment in relation to their most distressing sexual trauma (as identified on the CAPS-5; e.g., “Avoiding memories, thoughts, or feelings related to the stressful experience”) using a five-point Likert-type scale (0 = Not at all to 4 = Extremely). Responses were summed to create a total score for PTSD symptoms at each assessment, with higher scores indicating higher PTSD symptom severity. The PCL-5 has demonstrated convergent validity with other PTSD measures and discriminant validity with measures of antisocial personality disorder, mania, and depression (Blevins et al., 2015). This measure exhibited excellent reliability in evaluating between-person differences (Rkf = .99) and within-person change (RC = .92) in the present study.

Data Analysis

All analyses were conducted using SPSS, version 27.0. For data missing at random, expectation maximization was used to impute <1% of missing data points in order to utilize complete data from all participants in the sample (Tabachnick & Fidell, 2013). Means, standard deviations, and/or frequencies were calculated for all demographic and clinical variables and zero-order correlations were examined. Person-mean variables were calculated for daily PTSD symptoms and MC for inclusion in zero-order results. Independent samples t-tests were used to compare baseline trauma-related guilt, shame and MC scores for participants meeting PTSD criteria to participants not meeting PTSD criteria. Two separate, unconditional mixed linear regression models with random slopes and intercepts were run to determine whether there was a linear trend in MC or PTSD symptoms across daily assessments.

Primary analyses included two sets of hierarchical mixed linear regression models. The first set of models examined the individual and combined fixed effects of baseline trauma-related guilt (TRGI-guilt cognitions, TRGI-global guilt) and trauma-related shame (TRSI) in predicting daily sexual trauma-related MC (SMCS). Time (hours since first assessment) and baseline scores on the PEMC or CAPS-5 were included as covariates in Step 1 to control for linear trends in scores across the assessment period and the influence of constructs of interest at baseline, respectively. Age at first sexual violation and whether the assessment was completed on a weekend were evaluated as additional covariates but were not retained in the final model, as they were not significantly related to the outcomes of interest and no differences in results were obtained when these variables were included. In Step 2, a) TRSI or b) TRGI-guilt cognitions and TRGI-global guilt scores were alternately added, with the other score(s) added as a predictor(s) in Step 3. This approach allowed for an evaluation of whether trauma-related shame or trauma-related guilt at baseline prospectively predicted daily MC, and if that relationship remained significant after accounting for the other emotion. The second set of models included the same predictors and daily PTSD symptoms as an outcome. Daily MC and PTSD outcome scores were estimated in order to examine the influence of trauma-related shame and guilt on estimates of these constructs on a given day across the assessment period adjusting for covariates.

All continuous level-two predictors were grand-mean centered to aid in interpretation of intercepts and regression coefficients. Time was coded from −160 to 160 to reflect the number of hours that passed between assessment timepoints, with the midpoint being zero. All models utilized restricted maximum likelihood (REML) estimation and included the random intercept and slope of time. Covariance between the random intercept and slope was modeled using an unstructured covariance matrix. Covariance between timepoints was modeled using a first-order autoregressive structure (AR-1) to account for anticipated autocorrelation in daily assessment data. Model comparisons were conducted for nested models using a series of −2 log-likelihood (−2LL) comparisons via chi-square difference tests. Given the potential inflation of Type I error rates associated with multiple comparisons, a Benjamini-Hochberg adjusted critical p-value was calculated (Benjamini & Hochberg, 1995). This critical p-value was used for all analyses.

Results

A total of 30 participants (73.2%) reported two or more prior sexual traumas and 28 participants (68.3%) met criteria for PTSD. Participants with PTSD scored significantly higher than participants without PTSD on the PEMC, t(39) = 2.77, p = .01, and TRGI – global guilt subscale, t(39) = 2.34, p = .02. Scores on the TRSI, t(39) = 1.98, p = .06, and TRGI – guilt cognitions subscale, t(39) = 0.57, p = .57, did not differ by PTSD diagnostic status. Additional descriptive statistics and zero-order correlations among model variables are presented in Table 1. Trauma-related shame was positively correlated with both baseline and average daily levels of PTSD symptoms and MC. Global guilt was positively correlated with baseline and average daily PTSD symptoms and baseline MC only. Guilt cognitions were positively correlated with average daily PTSD symptoms but were not correlated with baseline PTSD symptoms or MC (baseline or daily). Between-person average scores for PTSD symptoms and MC over the 14-day assessment period were very highly correlated (r = .92); however, detrended measures of within-person variability in scores on the PCL-5 and SMCS were moderately to strongly correlated (.52 - .74) when examined via mean square successive difference (MSSD), supporting the discriminant validity of these measures at the daily level.

Table 1.

Descriptive Data and Zero-Order Correlations for Model Variables

Variable 1 2 3 4 5 6 7 M (SD) Range
1. Baseline mental contamination (PEMC) - .45** .36* .12 .50** .51** .51** 50.32 (14.67) 0 – 80
2. Baseline PTSD symptom severity (CAPS-5) - - .36* .27 .62** .59** .62** 32.17 (10.57) 0 – 80
3. Baseline trauma-related shame (TRSI) - - - .51** .43** .53** .54** 31.49 (17.27) 0 – 72
4. Baseline trauma-related guilt cognitions (TRGI) - - - - .63** .23 .33* 1.89 (0.86) 0 – 4
5. Baseline trauma-related global guilt (TRGI) - - - - - .29 .41** 2.24 (0.96) 0 – 4
6. Daily mental contamination (SMCS) - - - - - - .92** 14.33 (15.54) 0 – 60
7. Daily PTSD symptoms severity (PCL-5) - - - - - - - 24.10 (16.97) 0 – 80
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Note. *p < .05; **p < .01. Means and standard deviations for baseline mental contamination, baseline PTSD symptom severity, baseline trauma-related shame, baseline trauma-related guilt cognitions, baseline trauma-related global guilt, daily mental contamination, and daily PTSD symptom severity reflect average person-mean scores. CAPS-5 = Clinician-Administered PTSD Scale for DSM-5, PCL-5 = PTSD Checklist for DSM-5, PEMC = Posttraumatic Experience of Mental Contamination Scale, SMCS = State Mental Contamination Scale, TRSI = Trauma-Related Shame Inventory, TRGI = Trauma-Related Guilt Inventory.

There was no evidence of linear change in mental contamination, B = −0.002, SE = 0.005, t = −0.52, p = .61 or PTSD symptoms, B = −0.01, SE = 0.01, t = −0.82, p = .42 across the two-week assessment period in unconditional multilevel linear models, suggesting that there was no reactivity to daily diary procedures.

Primary Analyses

Table 2 displays results of the primary models predicting daily MC. In Step 1 of Model 1a, baseline MC was positively related to daily MC. In Step 2, trauma-related shame positively predicted daily MC. In Step 3, while controlling for trauma-related shame, neither trauma-related global guilt nor guilt cognitions significantly predicted daily MC. Model 1b displays results with trauma-related guilt cognitions and global guilt entered in Step 2 and trauma-related shame in Step 3. In Step 2, neither trauma-related guilt cognitions nor global guilt predicted daily MC when trauma-related shame was not included in the model. Trauma-related shame remained a significant positive predictor of daily MC when added in Step 3 after controlling for trauma-related global guilt and guilt cognitions. Table 3 displays results of the primary models predicting daily PTSD symptoms. In Step 1 of Model 2a, baseline PTSD symptoms were positively related to daily PTSD symptoms. In Step 2, trauma-related shame positively predicted daily PTSD symptoms. In Step 3, neither trauma-related guilt cognitions nor global guilt significantly predicted daily PTSD symptoms above and beyond the covariates and trauma-related shame. Model 2b shows the results with trauma-related guilt entered in Step 2 and trauma-related shame in Step 3. In Step 2, neither trauma-related guilt cognitions nor global guilt significantly predicted daily PTSD symptoms when trauma-related shame was not included in the model. Trauma-related shame remained a significant positive predictor of daily PTSD symptoms when added to Model 2b in Step 3, after controlling for trauma-related global guilt and guilt cognitions. The model including all predictors was identified as the model of best fit for both the MC and PTSD models based on −2 log-likelihood comparisons.

Table 2.

Hierarchical linear models of baseline trauma-related shame and guilt predicting daily mental contamination

B SE t Unadjusted
p-values		 95% Confidence
Interval		 B-H adjusted
p-Values
Model 1a
Step 1
 Intercept 14.38 2.11 6.80 <.001 [10.10, 18.66] <.001
 Hours −0.002 0.005 −0.53 .60 [−0.01, 0.01] .54
 PEMC 0.53 0.14 3.74 .001 [0.25, 0.82] .003
Step 2
 TRSI 0.42 0.11 3.68 .001 [0.19, 0.65] .003
Step 3
 TRGI – guilt cognitions 1.30 3.22 0.41 .69 [−5.22, 7.83] .52
 TRGI – global guilt −3.02 2.99 −1.01 .32 [−9.09, 3.05] .48
Model 1b
Step 2
 TRGI – guilt cognitions 5.30 3.24 1.63 .11 [−1.27, 11.88] .20
 TRGI – global guilt −3.01 3.33 −.90 .37 [−9.76, 3.75] .42
Step 3
 TRSI 0.44 0.13 3.27 .002 [0.17, 0.71] .005
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Note. PEMC = Posttraumatic Experience of Mental Contamination Scale, TRSI = Trauma-Related Shame Inventory, TRGI = Trauma-Related Guilt Inventory, B-H = Benjamini-Hochberg adjusted p-values.

Table 3.

Hierarchical linear models of effects of baseline trauma-related shame and guilt predicting daily PTSD symptoms

B SE t Unadjusted
p-values		 95% Confidence
Interval		 B-H adjusted
p-Values
Model 2a
Step 1
 Intercept 24.22 2.12 11.45 <.001 [19.94, 28.50] <.001
 Hours −0.01 0.01 −0.84 .41 [−0.02, 0.01] .33
 CAPS-5 0.90 0.19 4.69 <.001 [0.51, 1.29] <.001
Step 2
 TRSI 0.38 0.11 3.39 .002 [0.15, 0.61] .01
Step 3
 TRGI – guilt cognitions 3.07 2.99 1.02 .31 [−3.01, 9.14] .31
 TRGI – global guilt −4.07 3.07 −1.33 .19 [−10.29, 2.15] .29
Model 2b
Step 2
 TRGI – guilt cognitions 6.15 3.03 2.03 .05 [0.01, 12.28] .09
 TRGI – global guilt −3.86 3.35 −1.15 .26 [−10.65, 2.93] .29
Step 3
 TRSI 0.37 0.13 2.89 .01 [0.11, 0.62] .02
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Note. CAPS-5 = Clinician-Administered PTSD Scale for DSM-5, TRSI = Trauma-Related Shame Inventory, TRGI = Trauma-Related Guilt Inventory, B-H = Benjamini-Hochberg adjusted p-values.

Discussion

Shame and guilt are proposed to be involved in the development and maintenance of MC (Rachman, 1994, 2004; Rachman et al., 2015), and shame has been specifically highlighted in its purported role in MC following sexual victimization (Jung & Steil, 2013; Steil et al., 2011). While past research has investigated shame related to sexual trauma, the present study was the first to empirically test whether trauma-related shame and guilt prospectively predicted MC among women with a history of sexual trauma. The current study was also the first to use an experience sampling design to test whether trauma-related shame and guilt prospectively predicted sexual trauma-related PTSD symptoms in a daily context.

Consistent with hypotheses, trauma-related shame prospectively predicted higher daily MC, after accounting for trauma-related guilt (global guilt and guilt cognitions) and the covariates. In contrast, neither trauma-related global guilt nor guilt cognitions significantly predicted daily MC, either before or after trauma-related shame was included in the model. A similar pattern emerged for daily PTSD symptoms, wherein trauma-related shame prospectively predicted daily PTSD symptoms when accounting for trauma-related guilt and other covariates. However, neither trauma-related guilt cognitions nor global guilt significantly predicted daily PTSD symptoms, regardless of whether trauma-related shame was included in the model.

The present study demonstrated that trauma-related shame prospectively predicted daily sexual trauma-related MC and PTSD symptoms. However, the present findings did not support trauma-related guilt as a predictor of either MC or PTSD symptoms. This could be due to the differential roles these emotions serve in response to trauma. Shame involves general beliefs that one is terrible, unlovable, or unworthy (Tracy & Robins, 2004) and promotes avoidance of trauma reminders and social withdrawal, both of which maintain and worsen PTSD symptoms (Saraiya & Lopez-Castro, 2016; Tangney & Dearing, 2003). Negative self-appraisals following sexual trauma may lead to shame, which could perpetuate MC, subsequent avoidance of trauma reminders, and social withdrawal/isolation. Such avoidance may serve to prevent engagement with corrective information (Jung & Steil, 2013; Steil et al., 2011). In this way, trauma-related shame may increase risk for, perpetuate, or worsen PTSD symptoms and/or MC. This may be particularly true for MC if negative self-appraisals following sexual trauma involve perceptions regarding oneself as unclean, impure, or morally compromised (Rachman et al., 2015).

In contrast, guilt involves specific cognitions about how one should have acted, thought, or felt differently in a given situation (Kubany et al., 1995) and typically prompts reparative behaviors to mend perceived wrongdoing (Tangney et al., 1992). Indeed, research has demonstrated the predictive role of guilt on posttraumatic growth (Dekel et al., 2016). However, support for the relationship between trauma-related guilt and PTSD symptoms is mixed. For example, one meta-analysis (only including articles that distinguished between guilt and shame) reported significant correlations between guilt and all PTSD symptom clusters (Kip et al., 2022). Alternatively, several reviews have highlighted significant relationships between guilt and PTSD symptoms, though they also state that results are either potentially confounded by shame (Pugh et al., 2015), still significant, though fairly weak after controlling for shame (Shi et al., 2021), or not explicitly measuring constructs of guilt and shame (i.e., using studies only measuring posttraumatic cognitions; Gómez de La Cuesta et al., 2019). Additionally, several studies have demonstrated a stronger relationship between shame and PTSD symptoms compared to guilt (e.g., Bannister et al., 2019; Beck et al., 2011; Schoenleber et al., 2015).

Given that trauma-related shame and guilt often co-occur, our results highlight the importance of including assessments that discriminate between these two emotions. If trauma-related guilt is assessed in the absence of trauma-related shame, results may be conflated by the overlap between shame and guilt. Additionally, research on the role of these emotions in PTSD treatment has focused more on trauma-related guilt than trauma-related shame (e.g., Allard et al., 2018; Held et al., 2011; Kubany & Manke, 1995; Trachik et al., 2018); however, several studies have examined reductions in shame during treatment for PTSD (Ginzburg et al., 2009; Harned et al., 2014; Øktedalen et al., 2015; Resick et al., 2008). This is notable given evidence that trauma-related shame prospectively predicts changes in PTSD symptoms during treatment, but not vice versa (Ginzburg et al., 2009; Øktedalen et al., 2015).

Interestingly, levels of trauma-related shame did not significantly differ by PTSD diagnostic status. This is possibly because the study sample exhibited a range of PTSD symptoms, as opposed to groups with either clinically significant PTSD or no or low levels of PTSD. Therefore, the differences in PTSD severity between these groups may not have been stark enough to detect significant differences in trauma-related shame.

To date, there has been preliminary empirical consideration of MC as a target of trauma-focused treatment. For example, Cognitive Restructuring and Imagery Modification (CRIM; Jung & Steil, 2013) is a brief, adjunctive treatment protocol that has shown promise in reducing feelings of contamination in survivors of childhood sexual abuse compared to waitlist controls. However, reductions in MC have not been considered in gold-standard PTSD treatment trials. Future research would benefit from learning whether MC is reduced in evidence-based PTSD treatments in order to determine whether adjunctive interventions like CRIM might be useful among individuals with PTSD who also experience MC. Frequent tracking of trauma-related shame, MC, and PTSD symptoms throughout treatment is a critical area for future research in order to understand temporal associations among these constructs, especially in the context of interventions like CRIM or other trauma-focused treatments. It would also be useful for future studies to determine if changes in shame precipitate decreases in MC. If shame is operating similarly for MC and PTSD, as previously proposed, future studies should also identify unique risk factors for MC and PTSD following sexual trauma, as not everyone who develops PTSD also develops MC and vice versa. Finally, benchmarks for both clinical elevations and clinically significant change in MC are needed. Because cutoffs for the PEMC have not yet been established, additional interview questions were used to ensure that MC was a current problem for participants at the time of the in-person interview.

Several limitations should be considered. First, although detrended measures of short-term instability in daily MC and PTSD symptoms support the discriminant validity of these measures at the daily level, high correlations in the aggregate over the daily diary period suggest that further research is needed to bolster discriminant validity across daily measurements. Further work is also needed to develop measures that better distinguish between the non-overlapping elements of MC and PTSD at the daily level and when aggregated over repeated assessments. Second, as all participants in this study identified as women and were survivors of sexual trauma, results cannot generalize to individuals of other gender identities or to other trauma types. Though racial and ethnic diversity was largely reflective of the recruitment location demographics, and there was a high number of individuals who identified as sexual minorities in this sample, this study did not focus on considering how experiencing one or more marginalized identities may impact the associations between constructs of interest and this will be a critical area of future research. Third, though over half of participants met criteria for PTSD, replicating these results among a larger, entirely clinical sample would bolster reliability and generalizability. Fourth, self-reports are inherently subjective, which could influence the validity of results obtained compared to objective indicators of behavior that correspond with variables of study (e.g., frequency of washing behavior). Finally, we cannot know if the associations observed here would be maintained over a longer term, particularly in treatment contexts.

Despite limitations, the current study demonstrated that trauma-related shame prospectively predicts daily MC and PTSD symptoms following sexual trauma. This association remains robust even when accounting for the experience of trauma-related guilt. Further research is needed to better understand temporal relationships among trauma-related shame, MC, and PTSD symptoms, including how these factors interact and change in the context of treatment.

Acknowledgments

This work was supported, in part, by the Office for Policy Studies on Violence Against Women at the University of Kentucky. This project was also supported by the National Institute on Drug Abuse through grant number T32DA035200 as well as the National Center for Advancing Translational Sciences through grant number UL1TR001998 at the National Institutes of Health (NIH). The funding agencies had no role in study design, data collection or analysis, or preparation and submission of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or of the Office for Policy Studies on Violence Against Women.

Biographies

Jesse P. McCann, M.S. is a graduate student in the doctoral program in clinical psychology at the University of Kentucky. His research interests surround optimizing and streamlining empirically-supported interventions for posttraumatic stress disorder (PTSD) in order to improve both access to treatment as well as treatment outcomes.

Jordyn M. Tipsword, M.S. is a graduate student in the doctoral program in clinical psychology at the University of Kentucky. Her research focuses on emotional vulnerabilities that confer risk for posttraumatic stress disorder (PTSD) and other posttraumatic outcomes. Her work particularly emphasizes the role of self-focused emotions and associated phenomena in PTSD.

C. Alex Brake, Ph.D. received his doctoral degree at the University of Kentucky and completed postdoctoral training at Brown University. He currently practices within the Adult Partial Hospital Program at Rhode Island Hospital, where he delivers ACT-based and trauma-focused interventions. His research interests include emotional and mindfulness-based processes in the context of trauma-related symptoms and treatment.

Christal L. Badour, Ph.D. is an Associate Professor of Psychology at the University of Kentucky and Co-Director of the University of Kentucky Clinic for Emotional Health. Her research focuses on understanding the development, maintenance, and treatment of psychopathology following sexual violence and other traumatic experiences with an emphasis on affective experience, expression, and regulation.

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