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. Author manuscript; available in PMC: 2020 Sep 18.
Published in final edited form as: J Trauma Stress. 2019 Jul 10;32(4):484–495. doi: 10.1002/jts.22411

Association Between Shame and Posttraumatic Stress Disorder: A Meta-Analysis

Teresa López-Castro 1, Tanya Saraiya 1,2, Kathryn Zumberg-Smith 3, Naomi Dambreville 1,4
PMCID: PMC7500058  NIHMSID: NIHMS1628148  PMID: 31291483

Abstract

Posttraumatic stress disorder (PTSD) is a complex condition with affective components that extend beyond fear and anxiety. The emotion of shame has long been considered critical in the relation between trauma exposure and PTSD symptoms. Yet, to date, no meta-analytic synthesis of the empirical association between shame and PTSD has been conducted. To address this gap, the current study summarized the magnitude of the association between shame and PTSD symptoms after trauma exposure. A systematic literature search yielded 624 publications, which were screened for inclusion criteria (individuals exposed to a Criterion A trauma, and PTSD and shame assessed using validated measures of each construct). In total, 25 studies employing 3,663 participants met full eligibility criteria. A random-effects meta-analysis revealed a significant moderate association between shame and posttraumatic stress symptoms, r = .49, 95% CI [0.43, 0.55], p < .001. Moderator analyses were not completed due to the absence of between-study heterogeneity. Publication bias analyses revealed minimal bias, determined by small attenuation after the superimposition of weight functions. The results underscore that across a diverse set of populations, shame is characteristic for many individuals with PTSD and that it warrants a central role in understanding the affective structure of PTSD. Highlighting shame as an important clinical target may help improve the efficacy of established treatments. Future research examining shame’s interaction with other negative emotions and PTSD symptomology is recommended.

Over the course of the last decade, the primacy of fear and anxiety in our understanding of posttraumatic stress disorder (PTSD) has given way to the recognition that negative emotions other than fear contribute to PTSD’s development and course. It has been widely documented that traumatic exposure disrupts affective processes beyond the fear network (Lanius, Frewen, Nazarov, & McKinnon, 2013). For some individuals with PTSD, shame, sadness, or anger are more associated with the disorder’s clinical distress and functional impairment than pathological fear (Badour, Resnick, & Kilpatrick, 2015). The Diagnostic and Statistical Manual for Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) points to this increasing field-wide appreciation of negative affect in PTSD. Specifically, the previous requirement that individuals must experience fear, helplessness, or horror after trauma exposure has been removed and a new symptom cluster that captures alterations in negative cognitions and affect (e.g., guilt, shame, and anger) has been added. In the current study, we aimed to contribute to the understanding of one such emotion—shame—by conducting the first meta-analysis of the association between shame and posttraumatic stress symptoms.

Shame is a highly complex, socially important emotion that involves the negative evaluation of the self (Tracy & Robins, 2004). Like other self-conscious emotions (e.g., guilt and pride), shame requires frontal-cortical cognitive processing, which makes it distinct from basic emotions housed in limbic structures, such as disgust and fear (Lanius, Frewen, Vermetten, & Yehuda, 2010). From an evolutionary standpoint, group membership was necessary for survival, and shame may have evolved as an affective signal of social threat—social exclusion or rejection that jeopardizes survival (DeWall & Bushman, 2011). Threats to the preservation of the social self are thought to provoke a systematic psychophysiological reaction; shame is associated with a series of stress-related increases in proinflam-matory cytokines and cortisol (Dickerson, Kemeny, Aziz, Kim, & Fahey, 2004). Although these acute, threat-specific psychobiological reactions may initially be adaptive, the dysregulation or persistence of shame is known to exact a toll on physical health (Dickerson, Gruenewald, & Kemeny, 2004).

Historically, shame has been conflated with its sister emotion, guilt. Beginning with early work by Lewis (1971), efforts to differentiate shame conceptually and empirically from guilt have allowed for the development of nuanced lines of research dedicated to each emotion as well as meta-analytic pursuits, such as the current study. Lewis (1971) suggested that in shame, the individual judges the self—“I am bad”—whereas in guilt, the individual judges an action—”I did something bad” (see Gilbert, 2003, for other significant distinctions). Shame’s relationship with psychopathology has since been the subject of extensive scholarship (Gilbert & Andrews, 1998; Tangney & Dearing, 2002). Attention has been variedly paid to its interrelated components: affect (shame and shame blended with anger, anxiety, or disgust), cognitions and self-appraisals (the self as defective or unworthy), relational dynamics (shamer/shamed), and action tendencies (cowering, concealing, and aversion of eye contact). Understood as either state-dependent or dispositional, shame conceptualizations and measurements are numerous (Robins, Noftle, & Tracy, 2007). State measures of shame, such as the State Shame and Guilt Scale (SSGS; Marschall, Sanftner, & Tangney, 1994), assess an individual’s current experience of the emotion. Alternatively, dispositional shame, often referred to as “shame-proneness” or “trait shame,” is defined as the propensity for shame across an array of situations and measured with scenario-based scales like the Test of Self-Conscious Affect (TOSCA; Tangney, Dearing, Wagner, & Gramzow, 2000). Dispositional shame is also described as the frequency with which an individual experiences shame that is not tethered to any particular event; statement- and adjective-based checklists, such as the Internalized Shame Scale (ISS; Cook, 1988) and the Personal Feelings Questionnaire–2 (PFQ-2; Harder, Rockart, & Cutler, 1993), are often employed for assessment. Lastly, dispositional shame can be “domain-centered,” or related specifically to a personal characteristic or personal experience. Here, assessments that capture body shame and/or trauma-related shame are germane to PTSD.

Shame’s role in the etiology and course of PTSD has been charted by a rich collection of theoretical and clinical writings (Budden, 2009; Dunmore, Clark, & Ehlers, 2001; Nathanson, 1992). Contemporary cognitive models (Ehlers & Clark, 2000) posit that shame-based appraisals thwart the adaptive cognitive and affective processing of traumatic events. Others have conceptualized PTSD through a socioemotional lens (Budden, 2009; Sharp, Fonagy, & Allen, 2012) in which the disorder is potentially driven by the impact of dysregulated shame upon social cognition and interpersonal functioning. Working from the relational implications of childhood maltreatment, the traumagenic model (Finkelhor & Browne, 1985) identifies stigmatization—shame, badness, and guilt regarding the trauma—as one of the dynamics that gives rise to posttraumatic difficulties. The toxic distress triggered by shame has been understood to foster pathological avoidance through engaging in self-destructive and aggressive behaviors, withdrawing and isolating from others, or developing internalizing disorders, such as depression (Nathanson, 1992). Engagement in these unsuccessful efforts to downregulate shame may be one possible explanation for PTSD’s high comorbidity with depression and substance use disorders (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

Over the past two decades, empirical research has implicated various types of shame in the onset and persistence of posttraumatic distress. In trauma-exposed samples, unique associations between dispositional shame and negative self/other cognitions (Beck et al., 2015) and threat appraisals (Harman & Lee, 2010) have been documented. Both trauma-related and dispositional shame have predicted distress (Semb, Strömsten, Sundbom, Fransson, & Henningsson, 2011) and PTSD diagnosis (Brewin, Andrews, & Rose, 2000; Street & Arias, 2001) as well as the continuation of PTSD symptoms over time (Andrews, Brewin, Rose, & Kirk, 2000). In samples exposed to high impact traumas, such as childhood sexual abuse, a predictive chain has been documented wherein negative attributions are associated with shame about the traumatic experience, which, in turn, mediates the association with PTSD symptoms (Feiring, Taska, & Lewis, 2002). Research has also shown that the more global and stable the shame-based attributions following a trauma, the higher the likelihood of posttraumatic symptoms (Feiring, Taska, & Lewis, 1996; Robinaugh & McNally, 2010). For survivors of violence, autonomic arousal is often assumed to be driven by fear and anxiety, but recent psychophysiology data point to the contribution of shame. Trait shame rather than fear predicted increased arousal during exposure to trauma-related stimuli in a sample of interpersonal trauma–exposed women with PTSD (Freed & D’Andrea, 2015). However, whereas the body of empirical evidence for the association between shame and PTSD may appear robust, the widespread use of single-item inquiries and nonvalidated, study-specific surveys to measure shame have called into question the methodological quality of findings to date (Saraiya & Lopez-Castro, 2016).

Research has further sought to clarify how shame operates after certain types of trauma and within specific populations, thus suggesting key moderators of the relation between the emotion and PTSD. Epidemiological studies have reported a higher prevalence of PTSD in women than in men (Kessler, Chiu, Demler, Merikangas, & Walters, 2005), yet the contribution of shame to this disparity remains elusive. In likely reflection of gendered social norms, research has consistently found that women and girls are more shame-prone than men and boys (Tangney & Dearing, 2002). Evidence of gender differences in shame-related behaviors and appraisals after trauma exposure, however, has been inconsistent (Badour et al., 2015; Feiring et al., 2002). In addition to how shame may function differentially across genders, shame and stigmatization have been linked to human-generated trauma containing relational elements of domination and subjugation (Finkelhor & Browne, 1985; Kallstrom-Fuqua, Weston, & Marshall, 2004). A higher endorsement of shame has been found among individuals exposed to interpersonal violence as compared to noninterpersonal trauma (Ford, Stockton, Kaltman, & Green, 2006). Shame may also be a critical ingredient in combat-related PTSD. It is closely linked to moral injury (Litz et al., 2009), a concept that highlights the potential for moral transgressions during combat and its association with negative postdeployment functioning, including an increased risk for PTSD (Jordan, Eisen, Bolton, Nash, & Litz, 2017). Moreover, combat veterans show a stronger association between aggression and PTSD symptoms than civilians (Novaco & Chemtob, 2002). Recent work has suggested that shame may mediate this link between PTSD and aggression in veterans (Crocker, Haller, Norman, & Angkaw, 2016).

Given the empirical evidence suggestive of shame’s importance to the development and maintenance of PTSD, a next and critical step is to use a meta-analysis to quantify the degree of the association between shame and PTSD symptoms. By aggregating the results from relevant and methodologically rigorous studies performed to date, the findings of a metaanalysis can advance our understanding of the magnitude of shame’s influence on posttraumatic stress symptoms and thus spearhead future research. Capitalizing on the diverse samples and traumatic exposure types that have been investigated thus far, a meta-analytic investigation also affords the opportunity to examine the role of potential moderators in the association between shame and PTSD symptoms. If the meta-analytic association between shame and PTSD symptoms is impacted by a key variable, such as trauma type or gender, this knowledge may help inform if, how, and when shame should be therapeutically addressed.

To these ends, our study’s first aim was to determine the strength of the association between shame and PTSD symptoms in trauma-exposed individuals. In light of the substantial body of empirical work that has linked various types of shame to posttraumatic stress (Saraiya & Lopez-Castro, 2016), we included in our investigation the breadth of forms and definitions of shame that have been studied in relation to PTSD. We hypothesized that in trauma-exposed samples, a significant positive correlation between self-reported shame and PTSD symptoms would emerge. A second aim was to test moderators in the relation between shame and PTSD. We sought to explore the impact of gender, interpersonal violence exposure, and military involvement. Interpersonal violence was defined as acts of violence between individuals, regardless of whether the individuals are known to each other (Krug, Mercy, Dahlberg, & Zwi, 2002). With regard to gender, we refrained from a directional hypothesis due to divergent prior findings (Badour et al., 2015; Feiring et al., 2002). In line with prior work (Ford et al., 2006), we hypothesized that in contrast to studies with more noninterpersonal trauma exposure (e.g., environmental disasters, car accidents), a stronger association between shame and PTSD would be found among samples with higher rates of interpersonal violence. Lastly, given known associations between combat, shame, and PTSD (Litz et al., 2009), we hypothesized that veteran samples would demonstrate a stronger association between shame and PTSD symptoms than civilian samples.

Method

Search and Selection of Studies

We conducted a search of psychological and medical electronic literature databases, including Medline, PILOTS, and PsycInfo. The search dated from 1980 to June 2018 and employed the following search terms: (humiliat* OR embarrass* OR *shame*) AND (traumatic *stress OR post traumatic stress disorder OR post-traumatic stress disorder OR PTSD OR posttraumatic stress reactions OR posttraumatic stress OR PTSS). After duplicate records were removed, two authors (TLC & TS) completed the initial title and abstract review and full text review. Authors showed high agreement; disagreements were discussed by both authors until consensus was reached. To locate additional published studies, the references of relevant empirical and theoretical articles and book chapters were reviewed. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (Figure 1) illustrates the meta-analytic review process.

Figure 1.

Figure 1.

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PRISMA flow chart showing selection of studies for meta-analysis of shame and posttraumatic stress disorder symptoms. DSM = Diagnostic and Statistical Manual of Mental Disorders.

To be considered eligible, studies must have included: (a) participants who had experienced a Criterion A stressor according to the DSM (APA, 2013); (b) the use of a validated, self-report measure of shame; (c) the use of a validated measure of PTSD symptoms; and (d) a correlation (or sufficient information to calculate a correlation) between shame and PTSD symptoms. Studies were excluded on the following basis: (a) not peer-reviewed; (b) the article was a review or did not present new quantitative data; (c) single-case studies; (d) studies not written in English; and (e) if shame was not measured as a separate construct from other social emotional affects (e.g., guilt). Given questions regarding the completeness and risk of bias of unpublished data (van Driel, De Sutter, De Maeseneer, & Christiaens, 2009), inclusion was limited to peer-reviewed work. In terms of shame and PTSD assessment, we defined validation as a measure with at least one published citation of its psychometric properties. If one sample was analyzed by more than one eligible article, the article with the largest proportion of the total sample was selected. To the best of our knowledge, this occurred in one instance. Four eligible studies (Beck et al., 2011, 2015; Dodson & Beck, 2017; Tran & Beck, 2018) analyzed the same sample. Dodson and Beck (2017) was included because it had the largest number of participants (n = 202). In cases of longitudinal examinations of a sample, we included the article with the earliest time point that met our inclusion criteria (Feiring et al., 2002; Taal & Faber, 1998).

Data Extraction and Coding

Full text review and coding were completed using a piloted coding sheet. The following data were extracted: author, year, country, exclusion criteria, sample demographics, type of trauma exposure, proportion of sample exposed to interpersonal violence, PTSD measure, proportion of sample with a PTSD diagnosis, shame measure, DSM version, and association between shame and PTSD. Associations between shame and PTSD were extracted by recording either the reported Pearson correlation coefficient (r) and the sample size (in a trauma-exposed sample with varying degrees of posttraumatic stress symptoms and PTSD) or the means and standard deviations of a validated measure of shame in samples with trauma-exposed participants with and without PTSD. We used the effect size for the overall scale if effect sizes for multiple subscales were reported (Harman & Lee, 2010). Averages were calculated for studies that reported more than one shame outcome (Dorahy et al., 2013) or on multiple shame subscales without a total score (Neufeld, Sikkema, Lee, Kochman, & Hansen, 2012; Straub, McConnell, & Messman-Moore, 2018; Zerach & Levi-Belz, 2018). Borenstein, Hedges, Higgins, and Rothstein (2009) suggest the weighting of average effect sizes; however, recent work has shown that this may create potential bias by introducing a third, confounding variable in a random-effects meta-analysis (Shuster, 2010). For this reason, we refrained from using a weighted approach.

Selected studies were coded by two groups of two raters each. Each group reviewed half of the articles, and each article was coded by both raters on the same team to ensure accuracy. Interrater reliability was calculated using Cohen’s kappa for categorical variables and intraclass correlations (ICC) for continuous variables. Kappa values showed moderate to almost perfect agreement (Landis & Koch, 1977), and ICC values showed good and excellent agreement (Cicchetti, 1994). Disagreements were discussed with all raters to reach consensus.

Data Synthesis and Analysis

All coded effect sizes were converted from a Pearson correlation coefficient distribution into a Fisher-transformed distribution (ZFisher) due to the inherent skew at the tail ends of an r value distribution (Hedges & Olkin, 1983; Lipsey & Wilson, 2001). One study required effect size computation through provided means and standard deviations (Bockers, Roepke, Michael, Renneberg, & Knaevelsrud, 2015). All analyses were completed in ZFisher. Results were converted back into Pearson’s correlation coefficients (r values) for ease of interpretation.

Main effect size analyses were conducted using Field and Gillett’s (2010) SPSS syntax. We selected the Hedges–Vevea (1998) random effects approach a priori in order to generalize our findings to the population. A forest plot was used to visually inspect heterogeneity and potential outliers. Cochran’s Q was used to test heterogeneity in the effect size distribution, and the I2 (95% confidence interval) index was used to test heterogeneity due to effect size variability and sampling error.

To examine publication bias, we graphed a funnel plot (Figure 3) and applied the Vevea and Woods (2005) approach. The reason we elected this strategy was twofold: (a) the validity of funnel plots has been questioned due to their reliance on visual interpretation (Vevea & Woods, 2005) and (b) the traditionally employed Rosenthal’s failsafe N has been critiqued as a potentially inaccurate estimate, as values are based on significance rather than insignificance (Field & Gillett, 2010). Thus, Field and Gillet’s (2010) R script was used to test Vevea and Woods’s (2005) weight functions. These weight functions superimpose different parameters on the population of selected studies to detect how much effect sizes vary; high variation across different parameters suggests a high level of bias.

Figure 3.

Figure 3.

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Funnel plot mapping (k = 25) each study’s relative effect size by its standard error, an estimate for sampling variability.

Results

Table 1 provides sample characteristics, methods of assessment, and study effect sizes for the included studies. The final 25 studies involved a total of 3,663 participants with a mean age of 33.91 years (SD = 9.70), of whom 64.9% were women. Shame was most commonly measured using the PFQ-2 (20.0%) and the TOSCA (20.0%), followed by the ISS (12.0%) and the Abuse-Specific Shame Questionnaire (Feiring et al., 2002; 12.0%). The majority of the included research (60.0%) examined dispositional shame. Eight studies (32.0%) focused on domain-specific shame such as body-, illness-, or trauma-related shame; six of these studies investigated trauma-related shame.

Table 1.

Summary of Included Studies

Study N Gender (% female) Participants PTSD Measure Shame Measure r
Alix et al., 2017 147 100 Adolescent girls, CSA CITES-II ASSQ .66
Babcock Fenerci & DePrince, 2018 113 100 Online study, mothers, CSA TSC-40 TAQ .71
Bockers et al., 2015 60 100 Inpatient care, childhood abuse MINI TOSCA .34
Bryan et al., 2013 69 42 Outpatient care, active duty military PCL PFQ-2 .44
Crocker et al., 2016 127 5 Veterans, military-related trauma PCL ISS .60
DeCou et al., 2017 208 100 Undergraduates, sexual assault PCL-C ASSQ .58
Dodson & Beck, 2017 202 100 IPV, child abuse (n = 123) CAPS-IV ISS .35
Dorahy et al., 2013 65 32 Outpatient care, Northern Irish conflict SRC COSS PFQ-2 SSGS .37a
Dutra et al., 2008 107 84 Outpatient care, interpersonal trauma PDS YSQ-S .34
Feiring et al., 2002 147 73 Children and adolescents, CSA CITES-R ASSQ .66
Harman & Lee, 2010 46 53 Outpatient care PDS ESS .32
Held et al., 2015 72 32 Substance abuse treatment facility PCL-S SSGS .43
Lancaster & Erbes, 2017 182 20 MTurk study, veterans PCL-5 PFQ-2 .67
Lehavot et al., 2016 212 89b Online study, transgender veterans PCL-C TIS .44
Leskela et al., 2002 107 0 Veterans, prisoners of war PCL-M TOSCA .48
Maddox et al., 2011 22 95 Rape reported to police PDS ISS .57
McDermott et al., 2017 216 37 Online study, college veterans PCL-5 PFQ-2 .58
Neufeld et al., 2012 268 49 HIV-positive, CSA TSI HARSI .50c
Rhatigan et al., 2011 213 100 College students, sexual assault PCL TOSCA .45
Semb et al., 2011 35 49 Single violent crime HTQ TOSCA .47
Shin et al., 2014 38 100 Outpatient care, sexual assault PSS-SR PFQ-2 .39
Straub et al., 2018 326 100 MTurk study, sexual minority women PCL-5 GASP .11c
Street & Arias, 2001 61 100 Domestic violence shelters, IPV CMS TOSCA .47
Taal & Faber, 1998 429 36 Severe burn injuries IES BSHS-SV .61
Zerach & Levi-Belz, 2017 191 15 Online study, combat veterans PCL-5 TRSI .52c
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Note. ASSQ = Abuse-Specific Shame Questionnaire; BSHS-SV = Burn-Specific Health Scale-short version; CAPS = Clinician-Administered PTSD Scale; CITES-II = Children’s Impact of Traumatic Events Scale II; CITES-R = CITIES–Revised; CMS = Civilian Mississippi Scale for PTSD; COSS = Compass of Shame Scale; CSA = childhood sexual abuse; ESS = Experience of Shame Scale; GASP = Guilt and Shame-Proneness Scale; HARSI = HIV- and Abuse-Related Shame Inventory; HTQ = Harvard Trauma Questionnaire; IES = Impact of Events Scale; IPV = intimate partner violence; ISS = Internalized Shame Scale; MINI = Mini International Neuropsychiatric Interview; MTurk = Amazon’s Mechanical Turk; PCL = PTSD Checklist; PCL-5 = PCL for DSM 5; PCL-C = PCL–Civilian version; PCL-M = PCL–Military version; PCL-S = PCL–Specific Stressor version; PDS = Posttraumatic Stress Diagnostic Scale; PFQ2 = Harder Personal Feelings Questionnaire–2; PSS-SR = PTSD Symptoms Scale Self-Report; PTSD = posttraumatic stress disorder; SRC = Stress Reactions Checklist for Disorders of Extreme Stress; SSGS = State Shame and Guilt Scale; TAQ-10 = Trauma Appraisal Questionnaire; TIS = Transgender Identity Scale; TOSCA = Test of Self-Conscious Affect; TRSI = Trauma-Related Shame Inventory; TSC-40 = Trauma Symptom Checklist-40; TSI = Traumatic Symptom Inventory; YSQ-S = Young Schema Questionnaire-Short Form.

a

Average effect size of multiple measures.

b

Self-identified transwomen (male-to-female).

c

Average effect size of scale’s subscores.

The random-effects analysis (k = 25) yielded a significant, moderate mean effect size (Cohen, 1988) between shame and PTSD symptoms, r = .49, 95% CI [0.43, 0.55], p < .001. A forest plot of the associations between shame and PTSD symptoms for all studies can be found in Figure 2. From this plot, three effect sizes were identified as statistical outliers (Babcock Fenerci & DePrince, 2018; Lancaster & Erbes, 2017; Straub et al., 2018). The results of analysis of the heterogeneity of variance were nonsignificant, Q(24) = 18.23, p = .792, I2 = 0.00%, 95% CI [0.00%, 31.91%], indicating minimal between-study variance. Due to homogeneity between study effect sizes, planned moderator analyses were foregone.

Figure 2.

Figure 2.

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Forest plot of the associations between shame and posttraumatic stress disorder (PTSD) symptoms.

To test for publication bias, we began by visually inspecting the funnel plot (Figure 3). Most of the selected studies aggregated in a funnel shape around the population effect size, but seven studies fell outside of the 95% confidence intervals. Asymmetry suggests either study heterogeneity or publication bias. In particular, there appeared to be a bias toward the publication of studies with larger effect sizes and smaller standard errors, with fewer published studies of smaller samples with varying effect sizes. However, to further empirically assess the likelihood of publication bias, we applied four weight functions (Vevea & Woods, 2005) to our dataset: moderate one-tailed selection, severe one-tailed selection, moderate two-tailed selection, and severe two-tailed selection. The superimposition of these confidence intervals on collected study effect sizes provides an empirical estimate of bias. The overall unadjusted parameter estimate, r = .49, shifted minimally across these four parameters. Specifically, there was 0.50% attenuation for the moderate-one tailed selection, 1.03% attenuation for the severe one-tailed selection, 0.48% attenuation for the moderate two-tailed selection, and 1.03% attenuation for the severe two-tailed selection. Because single-digit percentage differences denote minimal attenuation of correlation values across different parameter bounds (Vevea & Woods, 2005), the calculated attenuations suggest minimal publication bias.

Discussion

Identifying key emotional mechanisms at play in PTSD is crucial for advancing efforts to model its course in trauma-exposed populations and enhancing the effectiveness of its treatment. The present meta-analysis took an important step toward the expansion of such an empirical base by documenting the association between shame and posttraumatic difficulties. In the 25 included studies, which had a combined sample size of 3,663, we found a moderate and reliable association between self-reported shame and PTSD symptoms. This correlation is noteworthy as it was demonstrated within a group of studies that largely employed PTSD measures predating the DSM-5 addition of symptom D4–Negative Affect (APA, 2013). The generalizability of the overall effect size is bolstered by the diversity of the data integrated, representing a breadth of sample characteristics (age, gender, trauma exposure, and country) and psychometrically sound measurement approaches. Although the current meta-analysis was limited to published research, the study’s application of weight functions suggested minimal publication bias. Our results are consistent with and extend upon recent findings reflecting the primacy of negative emotions other than fear in PTSD presentations. In a large sample (n = 1,522) of interpersonal trauma survivors, difficulties with anger and shame, uniquely and respectively, showed more robust associations with PTSD symptoms than persistent fear (Badour et al., 2015).

As an integration of the volume of empirical data to date, our findings provide substantial evidence that shame is important to PTSD symptomatology. Although the correlational nature of this meta-analysis prohibits causal or directional inferences, research suggests that shame is likely linked to PTSD through a web of biopsychosocial mechanisms. On a biological level, shame triggers a chain of threat-related processes that closely resemble those elicited by physical threat and pain (Eisen-berger, 2011). During and after traumatic experiences, the use of cognitive appraisals, such as self-blame, fuels persistent negative beliefs (i.e., “my life has changed for the worse”) and perceptions of the self as defective and reproachable (Dunmore et al., 2001). When unchecked, shame motivates social withdrawal and avoidance and isolates the trauma survivor from the potentially buffering and reparative force of social connection (Schumm, Briggs-Phillips, & Hobfoll, 2006).

The demonstrated strength of the association between shame and posttraumatic distress in traumatized samples carries clinical implications. Shame is a stressful, difficult-to-regulate emotion (Elison, Garofalo, & Velotti, 2014), and thus, its assessment and treatment can be clinically challenging. Yet, the results from this study underscore shame’s significant involvement in posttraumatic stress symptoms. As such, shame may be a fertile arena for therapeutic work and change. Understanding and addressing the role of shame in posttraumatic presentations should be integrated into diagnostic formulation and treatment planning. With accurate recognition by clinicians, empirically supported treatments for PTSD may provide the rudimentary frameworks for addressing pathological shame. A standard, shared component of processing therapies is the reevaluation of affective and cognitive responses to the trauma memory; these processing objectives provide a natural stage for working with dysregulated shame. If therapeutic attention can be brought to maladaptive shame, the clinician and client can begin the task of raising awareness and gradually altering problematic action tendencies and associated appraisals. Acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 2012) and compassion-focused therapies (Gilbert, 2009) that train the individual in decentering techniques may be especially beneficial in combatting the toxic effects of shame-related attributions and behavior. A therapeutic focus on shame may also serve as a highly influential treatment target that cuts across diagnostic lines. Amelioration of shame is likely to carry over to PTSD comorbidities with demonstrated propensities toward negative self-evaluation, such as depression (Kim, Thibodeau, & Jorgensen, 2011) and substance use disorders (Holl et al., 2016).

Several study limitations are important to note. First, we deviated from standard meta-analytic practice by not reviewing data from unpublished and gray literature sources (e.g. dissertations, book chapters, and conference proceedings). This is a significant study weakness because such an exclusion may lead to an overestimation of the pooled effect size due to publication bias (“file drawer problem”; Rosenthal, 1979). Despite the fact that identification of data from unpublished and gray sources remains a meta-analytic convention (Siddaway, Wood, & Hedges, 2019), controversy has persisted over the value of their pursuit and inclusion. In a recent contribution to this issue, the OPEN Consortium’s (Schmucker et al., 2017) systematic review showed a negligible impact of excluded unpublished and gray data on pooled effect estimates across medical fields. Nevertheless, the present findings should be interpreted as potentially inflated by this methodological limitation. Second, we further restricted inclusion to studies that employed psychometrically sound, validated measures of our two constructs of interest: shame and PTSD. By adhering to this standard of study quality, we lowered our pool of examined work and the potential range of effect sizes. Relatedly, the lack of between-study variance should not be equated with the absence of true moderation. The possibility remains that the number of selected studies may have led to low power to detect significant moderation (Hunter & Schmidt, 2004). As with all meta-analyses (Borenstein et al., 2009), the study was subject to the limitations of the included research. For instance, the selected studies employed self-report measures of shame, which carry inherent limitations due to the emotion’s highly aversive nature. Because the action tendencies associated with shame involve withdrawal and avoidance (Smith, Webster, Parrott, & Eyre, 2002), our conclusions regarding the role of shame in PTSD must account for the likelihood of underreporting. This divergence between the experience of shame and its self-report has been documented specifically in trauma-exposed samples (Bockers et al., 2015; Negrao, Bonanno, Noll, Putnam, & Trickett, 2005). The multimodal evaluation of shame—integrating physiological, subjective, and behavioral measures—marks the next step for clarifying the functional role of shame in posttraumatic distress. Furthermore, our meta-analysis examined the cross-sectional association between shame and PTSD; causal dynamics, such as whether shame leads to PTSD, PTSD leads to shame, or how these complex constructs interact with each other, could not be discerned.

Shame is multidimensional and spans behavioral, characterological, and bodily aspects (Andrews, Qian, & Valentine, 2002). For this meta-analysis, we focused on the broadest definition of shame, and, as such, we collapsed differences across investigations in the type and form of shame assessed. Modest correlations have been found between dispositional shame and trauma-related shame (Feiring & Taska, 2005; Rizvi, 2010), yet future research must address whether a specific type of shame (e.g., an overall propensity toward shame, shame in response to trauma, or state-level shame) is more relevant to PTSD than another type. Similarly, investigating moderators of the association between shame and PTSD, such as age at trauma exposure and trauma type, may be critical for shedding light on variations in risk and course of the disorder. Given the strength of the association between shame and PTSD found in the present study, a next step involves examining the role of shame regulation in potentiating and maintaining specific PTSD symptoms. Novel research on the subliminal processing of shame cues suggests the utility of modeling PTSD avoidance symptoms as maladaptive efforts to regulate shame (Sippel & Marshall, 2011). Another important future avenue of research involves the study of the relations between shame and other emotions. Although necessary by design for our primary aim, we must acknowledge the artificiality of examining shame and PTSD in isolation. The value of studying shame’s discrete association to posttraumatic symptoms is ultimately contingent upon its eventual integration into the larger, systematic endeavor to understand the broader social–cognitive–affective sequelae of trauma. Research should prioritize the examination of shame in the context of other negative emotions within PTSD, their interplay, and their bidirectional contribution to symptom presentation and therapeutic change. For instance, shame and anger may be particularly coupled and yield a synergistic effect that is worthy of further systematic investigation (Velotti, Elison, & Garofalo, 2014).

In conclusion, as the first meta-analysis to examine the aggregate association between shame and posttraumatic stress, our findings confirm a moderate and reliable association in a set of high-quality studies. Despite its limitations, our study suggests that shame is a meaningful affective marker and potentially central component of PTSD. As a complex, painful, and difficult emotion to recognize (Lewis, 1992), shame in the context of PTSD presents considerable challenges to both clinicians and researchers. To understand how shame may propel distress after trauma, future research must consider formalizing its assessment within standard diagnostic procedures of trauma-exposed samples. Investigation into how to therapeutically identify and reduce shame appears vital to patient care; working effectively with shame during PTSD treatment likely bolsters adherence, alliance, and outcomes (Herman, 2012). In conclusion, this meta-analysis facilitates these future systematic inquiries by synthesizing the robust empirical evidence for the association between shame and PTSD symptoms.

References

Asterisk denotes studies included in the meta-analysis.

  1. *Alix S, Cossette L, Hébert M, Cyr M, & Frappier J-Y (2017). Posttraumatic stress disorder and suicidal ideation among sexually abused adolescent girls: The mediating role of shame. Journal of Child Sexual Abuse, 26, 158–174. 10.1080/10538712.2017.1280577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. [Google Scholar]
  3. Andrews B, Brewin C, Rose S, & Kirk M (2000). Predicting PTSD symptoms in victims of violent crime: The role of shame, anger, and childhood abuse. Journal of Abnormal Psychology, 109, 69–73. 10.1037//0021-843x.109.1.69 [DOI] [PubMed] [Google Scholar]
  4. Andrews B, Qian M, & Valentine J (2002). Predicting depressive symptoms with a new measure of shame: The Experience of Shame Scale. The British Journal of Clinical Psychology, 41, 29–42. 10.1348/014466502163778 [DOI] [PubMed] [Google Scholar]
  5. *Babcock Fenerci R, & DePrince A (2018). Shame and alienation related to child maltreatment: Links to symptoms across generations. Psychological Trauma: Theory, Research, Practice, and Policy, 10, 419–426. 10.1037/tra0000332 [DOI] [PubMed] [Google Scholar]
  6. Badour C, Resnick H, & Kilpatrick D (2015). Associations between specific negative emotions and DSM-5 PTSD among a national sample of interpersonal trauma survivors. Journal of Interpersonal Violence, 32, 1620–1641. 10.1177/0886260515589930 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Beck J, McNiff J, Clapp J, Olsen S, Avery M, & Hagewood J (2011). Exploring negative emotion in women experiencing intimate partner violence: Shame, guilt, and PTSD. Behavior Therapy, 42, 740–750. 10.1016/j.beth.2011.04.001 [DOI] [PubMed] [Google Scholar]
  8. Beck J, Reich C, Woodward M, Olsen S, Jones J, & Patton S (2015). How do negative emotions relate to dysfunctional posttrauma cognitions? An examination of interpersonal trauma survivors. Psychological Trauma: Theory, Research, Practice and Policy, 7, 3–10. 10.1037/a0032716 [DOI] [PubMed] [Google Scholar]
  9. *Bockers E, Roepke S, Michael L, Renneberg B, & Knaevelsrud C (2015). The role of generalized explicit and implicit guilt and shame in interpersonal traumatization and posttraumatic stress disorder. Journal of Nervous and Mental Disease, 204, 95–99. 10.1097/NMD.0000000000000428 [DOI] [PubMed] [Google Scholar]
  10. Borenstein M, Hedges L, Higgins J, & Rothstein H (2009). Introduction to meta-analysis. Chichester, UK: John Wiley & Sons. [Google Scholar]
  11. Brewin C, Andrews B, & Rose S (2000). Fear, helplessness, and horror in posttraumatic stress disorder: Investigating DSM-IV Criterion A2 in victims of violent crime. Journal of Traumatic Stress, 13, 499–509. 10.1023/A:1007741526169 [DOI] [PubMed] [Google Scholar]
  12. *Bryan C, Morrow C, Etienne N, & Ray-Sannerud B (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety, 30, 55–60. 10.1002/da.22002 [DOI] [PubMed] [Google Scholar]
  13. Budden A (2009). The role of shame in posttraumatic stress disorder: A proposal for a socio-emotional model for DSM-5. Social Science & Medicine, 69, 1032–1039. 10.1016/j.socscimed.2009.07.032 [DOI] [PubMed] [Google Scholar]
  14. Cicchetti D (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284–290. 10.1037//1040-3590.6.4.284 [DOI] [Google Scholar]
  15. Cohen J (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates. [Google Scholar]
  16. Cook D (1988). Measuring shame. Alcoholism Treatment Quarterly, 4, 197–215. 10.1300/J020v04n02_12 [DOI] [Google Scholar]
  17. *Crocker L, Haller M, Norman S, & Angkaw A (2016). Shame versus trauma-related guilt as mediators of the relationship between PTSD symptoms and aggression among returning veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 520–527. 10.1037/tra0000151 [DOI] [PubMed] [Google Scholar]
  18. *DeCou C, Cole T, Lynch S, Wong M, & Matthews K (2017). Assault-related shame mediates the association between negative social reactions to disclosure of sexual assault and psychological distress. Psychological Trauma: Theory, Research, Practice, and Policy, 9, 166–172. 10.1037/tra0000186 [DOI] [PubMed] [Google Scholar]
  19. DeWall C, & Bushman B (2011). Social acceptance and rejection: The sweet and the bitter. Current Directions in Psychological Science, 20, 256–260. 10.1177/0963721411417545 [DOI] [Google Scholar]
  20. Dickerson S, Gruenewald T, & Kemeny M (2004). When the social self is threatened: Shame, physiology, and health. Journal of Personality, 72, 1191–1216. 10.1111/j.1467-6494.2004.00295.x [DOI] [PubMed] [Google Scholar]
  21. Dickerson S, Kemeny M, Aziz N, Kim K, & Fahey J (2004). Immuno-logical effects of induced shame and guilt. Psychosomatic Medicine, 66, 124–131. 10.1097/01.psy.0000097338.75454.29 [DOI] [PubMed] [Google Scholar]
  22. *Dodson T, & Beck J (2017). Posttraumatic stress disorder symptoms and attitudes about social support: Does shame matter? Journal of Anxiety Disorders, 47, 1–8. 10.1016/j.janxdis.2017.01.005 [DOI] [PubMed] [Google Scholar]
  23. *Dorahy M, Corry M, Shannon M, Webb K, McDermott B, Ryan M, & Dyer K (2013). Complex trauma and intimate relationships: the impact of shame, guilt and dissociation. Journal of Affective Disorders, 147, 72–79. 10.1016/j.jad.2012.10.010 [DOI] [PubMed] [Google Scholar]
  24. Dunmore E, Clark D, & Ehlers A (2001). A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 39, 1063–1084. 10.1016/S0005-7967(00)00088-7 [DOI] [PubMed] [Google Scholar]
  25. *Dutra L, Callahan K, Forman E, Mendelsohn M, & Herman J (2008). Core schemas and suicidality in a chronically traumatized population. The Journal of Nervous and Mental Disease, 196, 71–74. 10.1097/NMD.0b013e31815fa4c1 [DOI] [PubMed] [Google Scholar]
  26. Ehlers A, & Clark D (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345. 10.1016/S0005-7967(99)00123-0 [DOI] [PubMed] [Google Scholar]
  27. Eisenberger N (2011). Why rejection hurts: What social neuroscience has revealed about the brain’s response to social rejection. The Handbook of Social Neuroscience, 586–598. 10.1093/oxfordhb/9780195342161.013.0039 [DOI]
  28. Elison J, Garofalo C, & Velotti P (2014). Shame and aggression: Theoretical considerations. Aggression and Violent Behavior, 19, 447–453. 10.1016/j.avb.2014.05.002 [DOI] [Google Scholar]
  29. Feiring C, & Taska L (2005). The persistence of shame following sexual abuse: A longitudinal look at risk and recovery. Child Maltreatment, 10, 337–349. [DOI] [PubMed] [Google Scholar]
  30. Feiring C, Taska L, & Lewis M (1996). A process model for understanding adaptation to sexual abuse: The role of shame in defining stigmatization. Child Abuse and Neglect, 20, 767–782. 10.1016/0145-2134(96)00064-6 [DOI] [PubMed] [Google Scholar]
  31. *Feiring C, Taska L, & Lewis M (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38, 79–92. 10.1037//0012-1649.38.1.79 [DOI] [PubMed] [Google Scholar]
  32. Field A, & Gillett R (2010). How to do a meta-analysis. British Journal of Mathematical and Statistical Psychology, 63, 665–694. 10.1348/000711010X502733 [DOI] [PubMed] [Google Scholar]
  33. Finkelhor D, & Browne A (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55, 530–541. 10.1111/j.1939-0025.1985.tb02703.x [DOI] [PubMed] [Google Scholar]
  34. Ford J, Stockton P, Kaltman S, & Green B (2006). Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women. Journal of Interpersonal Violence, 21, 1399–1416. 10.1177/0886260506292992 [DOI] [PubMed] [Google Scholar]
  35. Freed S, & D’Andrea W (2015). Autonomic arousal and emotion in victims of interpersonal violence: Shame proneness but not anxiety predicts vagal tone. Journal of Trauma & Dissociation, 16, 367–383. 10.1080/15299732.2015.1004771 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Gilbert P (2003). Evolution, social roles, and the differences in shame and guilt. Social Research, 70, 1205–1230. [Google Scholar]
  37. Gilbert P (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment, 15, 199–208. 10.1192/apt.bp.107.005264 [DOI] [Google Scholar]
  38. Gilbert P, & Andrews B (1998). Shame: Interpersonal behavior, psychopathology, and culture. Oxford, UK: Oxford University Press. [Google Scholar]
  39. Harder D, Rockart L, & Cutler L (1993). Additional validity evidence for the Harder Personal Feelings Questionnaire-2 (PFQ2): A measure of shame and guilt proneness. Journal of Clinical Psychology, 49, 345–348. [DOI] [PubMed] [Google Scholar]
  40. *Harman R, & Lee D (2010). The role of shame and self-critical thinking in the development and maintenance of current threat in posttraumatic stress disorder. Clinical Psychology and Psychotherapy, 17, 13–24. 10.1002/cpp.636 [DOI] [PubMed] [Google Scholar]
  41. Hayes S, Strosahl K, & Wilson K (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press. [Google Scholar]
  42. Hedges L, & Olkin I (1983). Regression models in research synthesis. The American Statistician, 37, 137–140. [Google Scholar]
  43. Hedges L, & Vevea J (1998). Fixed- and random-effects models in meta-analysis. Psychological Methods, 3, 486–504. 10.1037//1082-989x.3.4.486 [DOI] [Google Scholar]
  44. *Held P, Owens G, & Anderson S (2015). The interrelationships among trauma-related guilt and shame, disengagement coping, and PTSD in a sample of treatment-seeking substance users. Traumatology, 21, 285–292. 10.1037/trm0000050 [DOI] [Google Scholar]
  45. Herman J (2012). Shattered shame states and their repair In Yellin J & White K (Eds.), Shattered states: Disorganised attachment and its repair (pp. 157–170). London, United Kingdom: Karnac Books, Ltd. [Google Scholar]
  46. Holl J, Wolff S, Schumacher M, Höcker A, Arens E, Spindler G, … Schäfer I (2017). Substance use to regulate intense posttraumatic shame in individuals with childhood abuse and neglect. Development and Psychopathology, 29, 737–749. 10.1017/S0954579416000432 [DOI] [PubMed] [Google Scholar]
  47. Hunter J, & Schmidt F (2004). Methods of meta-analysis: Correcting error and bias in research findings (2nd ed.). Thousand Oaks, CA: SAGE Publications. [Google Scholar]
  48. Jordan A, Eisen E, Bolton E, Nash W, & Litz B (2017). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice and Policy, 9, 627–634. 10.1037/tra0000249 [DOI] [PubMed] [Google Scholar]
  49. Kallstrom-Fuqua A, Weston R, & Marshall L (2004). Childhood and adolescent sexual abuse of community women: Mediated effects on psychological distress and social relationships. Journal of Consulting and Clinical Psychology, 72, 980–992. 10.1037/0022-006x.72.6.980 [DOI] [PubMed] [Google Scholar]
  50. Kessler R, Chiu W, Demler O, Merikangas K, & Walters E (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–27. 10.1001/archpsyc.62.6.617 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Kessler R, Sonnega A, Bromet E, Hughes M, & Nelson C (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. 10.1001/archpsyc.1995.03950240066012 [DOI] [PubMed] [Google Scholar]
  52. Kim S, Thibodeau R, & Jorgensen R (2011). Shame, guilt, and depressive symptoms: A meta-analytic review. Psychological Bulletin, 137, 68–96. 10.1037/a0021466 [DOI] [PubMed] [Google Scholar]
  53. Krug E, Mercy J, Dahlberg L, & Zwi A (2002). The world report on violence and health. The Lancet, 360, 1083–1088. 10.1016/S0140-6736(02)11133-0 [DOI] [PubMed] [Google Scholar]
  54. *Lancaster S, & Erbes C (2017). Importance of moral appraisals in military veterans. Traumatology, 23, 317–322. 10.1037/trm0000123 [DOI] [Google Scholar]
  55. Landis J, & Koch G (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174. 10.2307/2529310 [DOI] [PubMed] [Google Scholar]
  56. Lanius R, Frewen P, Nazarov A, & McKinnon M (2013). A social-cognitive-neuroscience approach to PTSD: Clinical and research perspectives In Lanius U, Corrigan F, & Paulsen S (Eds.), Neurobiology and treatment of traumatic dissociation: Towards an embodied self (pp. 69–80). New York, NY: Springer. [Google Scholar]
  57. Lanius R, Frewen P, Vermetten E, & Yehuda R (2010). Fear conditioning and early life vulnerabilities: Two distinct pathways of emotional dysregulation and brain dysfunction in PTSD. European Journal of Psychotraumatology, 1, 5467 10.3402/ejpt.v1i0.5467 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. *Lehavot K, Simpson T, & Shipherd J (2016). Factors associated with suicidality among a national sample of transgender veterans. Suicide and Life-Threatening Behavior, 46, 507–524. 10.1111/sltb.12233 [DOI] [PubMed] [Google Scholar]
  59. *Leskela J, Dieperink M, & Thuras P (2002). Shame and posttraumatic stress disorder. Journal of Traumatic Stress, 15, 223–226. 10.1023/A:1015255311837 [DOI] [PubMed] [Google Scholar]
  60. Lewis H (1971). Shame and guilt in neurosis. New York, NY: International Universities Press. [Google Scholar]
  61. Lewis M (1992). Shame: The exposed self. New York: Free Press. [Google Scholar]
  62. Lipsey MW, & Wilson D (2001). Practical meta-analysis. Thousand Oaks, CA: SAGE Publications. [Google Scholar]
  63. Litz B, Stein N, Delaney E, Lebowitz L, Nash W, Silva C, & Maguen S (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. 10.1016/j.cpr.2009.07.003 [DOI] [PubMed] [Google Scholar]
  64. *Maddox L, Lee D, & Barker C (2011). Police empathy and victim PTSD as potential factors in rape case attrition. Journal of Police and Criminal Psychology, 26, 112–117. 10.1007/s11896-010-9075-6 [DOI] [Google Scholar]
  65. Marschall D, Sanftner J, & Tangney J (1994). The State Shame and Guilt Scale. Fairfax, VA: George Mason University. [Google Scholar]
  66. *McDermott R, Currier J, Naylor P, & Kuhlman S (2017). Student veterans’ self-stigma of seeking help: Contributions of painful self-conscious emotions, traditional masculine norms, and war-zone service. Psychology of Men & Masculinity, 18, 226–237. 10.1037/men0000117 [DOI] [Google Scholar]
  67. Nathanson DL (1992). Shame and pride: Affect, sex, and the birth of the self. New York, NY: Norton. [Google Scholar]
  68. Negrao C, Bonanno G, Noll J, Putnam F, & Trickett P (2005). Shame, humiliation, and childhood sexual abuse: Distinct contributions and emotional coherence. Child Maltreatment, 10, 350–363. 10.1177/1077559505279366 [DOI] [PubMed] [Google Scholar]
  69. *Neufeld S, Sikkema K, Lee R, Kochman A, & Hansen N (2012). The development and psychometric properties of the HIV and Abuse Related Shame Inventory (HARSI). AIDS and Behavior, 16, 1063–1074. 10.1007/s10461-011-0086-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Novaco R, & Chemtob C (2002). Anger and combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 15, 123–132. 10.1023/a:1014855924072 [DOI] [PubMed] [Google Scholar]
  71. *Rhatigan D, Shorey R, & Nathanson A (2011). The impact of posttraumatic symptoms on women’s commitment to a hypothetical violent relationship: A path analytic test of posttraumatic stress, depression, shame, and self-efficacy on investment model factors. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 181–191. 10.1037/a0020646 [DOI] [Google Scholar]
  72. Rizvi S (2010). Development and preliminary validation of a new measure to assess shame: The Shame Inventory. Journal of Psychopathology and Behavioral Assessment, 32, 438–447. 10.1007/s10862-009-9172-y [DOI] [Google Scholar]
  73. Robinaugh D, & McNally R (2010). Autobiographical memory for shame or guilt provoking events: Association with psychological symptoms. Behaviour Research and Therapy, 48, 646–652. 10.1016/j.brat.2010.03.017 [DOI] [PubMed] [Google Scholar]
  74. Robins R, Noftle E, & Tracy J (2007). Assessing self-conscious emotions: A review of self-report and nonverbal measures In The Self-Conscious Emotions; Theory and Research. New York, NY: Guilford Press. [Google Scholar]
  75. Rosenthal R (1979). The file drawer problem and tolerance for null results. Psychological Bulletin, 86, 638–641. 10.1037//0033-2909.86.3.638 [DOI] [Google Scholar]
  76. Saraiya T, & Lopez-Castro T (2016). Ashamed and afraid: A scoping review of the role of shame in post-traumatic stress disorder (PTSD). Journal of Clinical Medicine, 5, 94 10.3390/jcm5110094 [DOI] [PMC free article] [PubMed] [Google Scholar]
  77. Schmucker CM, Blümle A, Schell LK, Schwarzer G, Oeller P, Cabrera L, … Meerpohl JJ (2017). Systematic review finds that study data not published in full text articles have unclear impact on meta-analyses results in medical research. PloS One, 12, e0176210 10.1371/journal.pone.0176210 [DOI] [PMC free article] [PubMed] [Google Scholar]
  78. Schumm J, Briggs-Phillips M, & Hobfoll S (2006). Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women. Journal of Traumatic Stress, 19, 825–836. 10.1002/jts.20159 [DOI] [PubMed] [Google Scholar]
  79. *Semb O, Strömsten L, Sundbom E, Fransson P, & Henningsson M (2011). Distress after a single violent crime: How shame-proneness and event-related shame work together as risk factors for post-victimization symptoms. Psychological Reports, 109, 3–23. 10.2466/02.09.15.16.pr0.109.4.3-23 [DOI] [PubMed] [Google Scholar]
  80. Siddaway AP, Wood AM, & Hedges LV (2019). How to do a systematic review: A best practice guide to conducting and reporting narrative reviews, meta-analyses, and meta-syntheses. Annual Review of Psychology, 70, 747–770. [DOI] [PubMed] [Google Scholar]
  81. Sharp C, Fonagy P, & Allen J (2012). Posttraumatic stress disorder: A social-cognitive perspective. Clinical Psychology: Science and Practice, 19, 229–240. 10.1111/cpsp.12002 [DOI] [Google Scholar]
  82. *Shin K, Cho S-M, Lee S, & Chung Y (2014). A pilot prospective study of the relationship among cognitive factors, shame, and guilt proneness on posttraumatic stress disorder symptoms in female victims of sexual violence. Journal of Korean Medical Science, 29, 831–836. 10.3346/jkms.2014.29.6.831 [DOI] [PMC free article] [PubMed] [Google Scholar]
  83. Shuster J (2010). Empirical vs. natural weighting in random effects meta-analysis. Statistics in Medicine, 29, 1259–1265. 10.1002/sim.3607 [DOI] [PMC free article] [PubMed] [Google Scholar]
  84. Sippel LM, & Marshall AD (2011). Posttraumatic stress disorder symptoms, intimate partner violence perpetration, and the mediating role of shame processing bias. Journal of Anxiety Disorders, 25, 903–910. 10.1016/j.janxdis.2011.05.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  85. Smith R, Webster J, Parrott W, & Eyre H (2002). The role of public exposure in moral and nonmoral shame and guilt. Journal of Personality and Social Psychology, 83, 138–159. 10.1037//0022-3514.83.1.138 [DOI] [PubMed] [Google Scholar]
  86. *Straub K, McConnell A, & Messman-Moore T (2018). Internalized heterosexism and posttraumatic stress disorder symptoms: The mediating role of shame proneness among trauma-exposed sexual minority women. Psychology of Sexual Orientation and Gender Diversity, 5, 99–108. 10.1037/sgd0000263 [DOI] [Google Scholar]
  87. *Street A, & Arias I (2001). Psychological abuse and posttraumatic stress disorder in battered women: Examining the roles of shame and guilt. Violence and Victims, 16, 65–78. 10.1891/0886-6708.16.1.65 [DOI] [PubMed] [Google Scholar]
  88. *Taal L, & Faber A (1998). Posttraumatic stress and maladjustment among adult burn survivors 1–2 years postburn. Burns, 24, 285–292. [DOI] [PubMed] [Google Scholar]
  89. Tangney J, & Dearing R (2002). Shame and guilt. New York, NY: Guilford Press. [Google Scholar]
  90. Tangney J, Dearing R, Wagner P, & Gramzow R (2000). The Test of Self-Conscious Affect-short form (TOSCA-S). George Mason University, Fairfax, VA. [Google Scholar]
  91. Tracy J, & Robins R (2004). Putting the self into self-conscious emotions: A theoretical model. Psychological Inquiry, 15, 103–125. 10.1207/s15327965pli1502_01 [DOI] [Google Scholar]
  92. Tran HN, & Beck JG (2018). Are peritraumatic perceptions of fear/life threat and posttraumatic negative self-conscious appraisals/emotions differentially associated with PTSD symptoms? Cognitive Therapy & Research, 43, 272–283. 10.1007/s10608-018-9903-z [DOI] [Google Scholar]
  93. Van Driel ML, De Sutter A, De Maeseneer J, & Christiaens T (2009). Searching for unpublished trials in Cochrane reviews may not be worth the effort. Journal of Clinical Epidemiology, 62, 838–844. 10.1016/j.jclinepi.2008.09.010 [DOI] [PubMed] [Google Scholar]
  94. Velotti P, Elison J, & Garofalo C (2014). Shame and aggression: Different trajectories and implications. Aggression and Violent Behavior, 19, 454–461. 10.1016/j.avb.2014.04.011 [DOI] [Google Scholar]
  95. Vevea J, & Woods C (2005). Publication bias in research synthesis: Sensitivity analysis using a priori weight functions. Psychological Methods, 10, 428–443. 10.1037/1082-989X.10.4.428 [DOI] [PubMed] [Google Scholar]
  96. *Zerach G, & Levi-Belz Y (2018). Moral injury process and its psychological consequences among Israeli combat veterans. Journal of Clinical Psychology, 74, 1526–1544. 10.1002/jclp.22598 [DOI] [PubMed] [Google Scholar]

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