Shame, guilt, and posttraumatic stress symptoms: A three-level meta-analysis

Assessing neurocognitive outcomes in PTSD: a multilevel meta-analytical approach

Background: Evidence supporting the association between posttraumatic stress disorder (PTSD) and cognitive impairment is accumulating. However, less is known about which factors influence this association.Objective: The aims of this meta-analysis were to (1) elucidate the association between PTSD and a broad spectrum of cognitive impairment, including the risk of developing neurocognitive disorder (NCD) later in life, using a multilevel meta-analytic approach, and (2) identify potential moderating factors of this association by examining the effects of age (20-39, 40-59, 60+), study design (cross-sectional or longitudinal), study population (war-exposed populations/veterans or the general population), neurocognitive outcome assessed (i.e. a diagnosis of NCD or type of cognitive domain as classified according to A Compendium of Neuropsychological tests), gender (≥50% women or <50% women), study quality (high vs low), type of PTSD measure (self-report or clinical diagnosis), as well as the presence of comorbidities such as traumatic brain injury (TBI), depression, and substance use (all coded as either present or absent).Method: Peer-reviewed studies on this topic were extracted from PubMed and Web of Science with predetermined keywords and criteria. In total, 53 articles met the criteria. Hedge's g effect sizes were calculated for each study and a three-level random effect meta-analysis conducted.Results: After accounting for publication bias, the results suggested a significant association between PTSD and cognitive impairment, g = 0.13 (95% CI: 0.10-0.17), indicating a small effect. This association was consistent across all examined moderators, including various neurocognitive outcomes, age, gender, study design, study population, study quality, type of PTSD measure, and comorbidities such as depression, substance use, and TBI.Conclusions: These findings collectively suggest that PTSD is associated with both cognitive impairment and NCD. This emphasizes the need for early intervention (including prevention strategies) of PTSD, alongside monitoring cognitive function in affected individuals.International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42021219189, date of registration: 02.01.2021.

C-METTA reduces PTSD-related guilt and shame following interpersonal violence

Background: PTSD patients who experienced interpersonal violence are susceptible to trauma-related guilt and shame and often show unsatisfactory treatment response. C-METTA combines cognitive techniques and loving-kindness meditation. It has shown promising effects in reducing trauma-related guilt and shame.Objective: We examined the effectiveness of C-METTA within a quasi-experimental one-group pretest-posttest trial focusing on survivors of interpersonal violence, who suffered from trauma-related guilt and shame. An additional objective was to examine variables potentially associated with lower treatment response (childhood trauma, cumulative trauma, and PTSD chronicity).Method: We treated 25 individuals (age = 19-61, 96% women) with PTSD following interpersonal violence. We predicted that C-METTA would significantly reduce (a) PTSD symptoms (measured by the Clinician Administered PTSD Scale, the PTSD Symptom-Checklist Version 5, and the Posttraumatic Cognitions Inventory), (b) feelings of guilt (measured by the Trauma Related Guilt Inventory) and (c) feelings of shame (measured by the Trauma Related Shame Inventory). To analyse treatment effects, we conducted repeated-measures MANOVAs. Further, we investigated the impact of childhood trauma, cumulative trauma and PTSD chronicity symptoms on treatment effectiveness exploratively via additional MANCOVAs.Results: Analyses showed significant and large effects of C-METTA on reducing PTSD symptoms (ranging from d = 1.12 to d = 1.67), feelings of guilt (d = 1.54) and shame (d = 1.26). Childhood trauma, cumulative trauma and PTSD chronicity did not affect treatment effectiveness.Conclusion: Our findings support previous research concerning the effectiveness of C-METTA and add promising evidence for the effectiveness of C-METTA to reduce PTSD following interpersonal violence. Effectiveness was independent of childhood trauma, trauma-duration and PTSD chronicity. Regression to the mean should be considered as a confounding factor. We suggest more research to support the results. C-METTA might increase PTSD treatment diversity and offer patients a greater bandwidth of options according to their preferences and the respective symptomatology.

Resilience in diversity: a restricted range of roles is associated with more severe moral injury

BACKGROUND

Moral injury is a potentially deleterious mental health outcome that can follow exposure to events that challenge one's moral code. Theoretical models suggest a multi-faceted self-concept may support adaptation following such events. However, little is known about the relationship between self-concept complexity and outcomes following potentially morally injurious events.

AIMS

This cross-sectional study investigated hypothesized relationships between self-concept complexity and outcomes in adults (n=172) exposed to potentially morally injurious events.

METHOD

Participants completed validated measures of event-related distress, traumatic stress, depression and anxiety, and a self-complexity task in which they provided multiple descriptors of their self-concept. Responses were coded for overall diversity, defined as number of categories of self-descriptors, and role diversity, defined as number of social and activity-based roles.

RESULTS

Multiple regression analyses found greater role diversity independently predicted lower event-related distress, while overall self-diversity and total number of self-descriptors did not.

CONCLUSION

Findings indicate diversity in active facets of the self (e.g. relational or activity-based roles) may buffer the effects of a potentially morally injurious event.

Trauma-related guilt, shame, and trauma type among patients with co-occurring PTSD and SUD

BACKGROUND

Substance use disorder (SUD) frequently co-occurs with posttraumatic stress disorder (PTSD). Feelings of shame and guilt are associated with either disorder but have not been studied in patients with both disorders. Index trauma characteristics are associated with PTSD severity and trauma-related shame. This study examines the effects of trauma-related guilt and shame, and index trauma on SUD and PTSD severity in a clinical sample of individuals with co-occurring SUD and PTSD.

METHODS

Participants were SUD-treatment-seeking patients with co-occurring PTSD (N = 209) who completed the Clinician-Administered PTSD scale for Diagnostic and Statistical Manual of Mental Disorders (DSM-5; CAPS-5), Alcohol Use Disorder Identification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT), Trauma-Related Guilt Inventory (TRGI) and Trauma-Related Shame Inventory (TRSI). Regression analyses examined the predictive values of PTSD severity, trauma-related guilt, and shame on alcohol and drug use problems, and the predictive values of trauma-related guilt and shame on PTSD severity. One-way ANOVA and follow-up t-tests examined the effects of index trauma on PTSD severity and trauma-related shame.

RESULTS

PTSD severity was significantly associated with drug use disorder (DUD) severity and showed a curvilinear relationship to alcohol use disorder (AUD) severity. Trauma-related guilt was not significantly associated with SUD severity, while trauma-related shame was significantly associated with DUD severity (but not AUD severity). Both trauma-related guilt and shame were significantly associated with PTSD severity; however, only trauma-related shame showed an independent association. Interpersonal (especially sexual) index traumas were associated with increased trauma-related guilt and shame, while childhood index traumas were associated with increased PTSD severity.

CONCLUSIONS

Trauma-related guilt and shame might be important focus points in PTSD treatment, but for SUD problems, this study only showed an association between trauma-related shame and drug use problems. Trauma-related shame seems to be a more important treatment focus point than trauma-related guilt in the treatment of PTSD. It becomes particularly relevant for interpersonal index traumas (especially sexual trauma). Childhood traumas require attention in SUD-PTSD co-occurrence, given the higher severity of PTSD.

Digital Psychological Interventions for Adults in the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

This study evaluates the effect of digital psychological interventions on anxiety, depression, and stress symptoms in adults affected by the pandemic. A systematic search across five digital databases, from 1 January 2020 to 6 March 2024, identified 36 studies encompassing 8,662 participants. Compared with all control conditions, random-effects meta-analyses indicated that digital psychological interventions significantly reduced anxiety (g = -0.374; 95% CI, -0.529 to -0.218), depression (g = -0.568; 95% CI, -0.776 to -0.360), and stress (g = -0.452; 95% CI, -0.608 to -0.295). Smaller effect sizes were observed when compared with active controls than with inactive controls. Notable heterogeneity across three outcomes was observed. Publication bias was noted in depression symptoms. Several moderators were identified compared with inactive controls, including participant type for anxiety (psubgroup = 0.005), and region for depression symptoms (psubgroup = 0.000). Larger sample sizes (b = 0.0004; p = 0.028) related to stronger effects on depression symptoms. Publication year positively correlated with effects on stress (b = 0.1573; p = 0.032). This study supports the efficacy of digital psychological interventions in alleviating anxiety, depression, and stress symptoms for adults during the pandemic, offering insights for developing targeted mental health strategies in future public health crises.

Mindfulness affected post-traumatic stress symptoms and post-traumatic growth: Adaptive and maladaptive sides through trauma-related shame and guilt

Mindfulness plays an important role in reducing post-traumatic stress symptoms (PTSS) and promoting posttraumatic growth (PTG) among traumatized populations. However, the mechanism at the emotional level has not been fully examined. Thus, we aimed to investigate the possible mediating roles of trauma-related shame and guilt. A total of 814 college students (M age = 19.55, SD = 1.89) with traumatic experiences in China were recruited. Traumatic experiences, mindfulness, trauma-related shame, and trauma-related guilt were assessed in the first survey. Six months later, PTSS and PTG were assessed in the second survey. Structural equation modeling (SEM) analysis indicated that mindfulness was associated with less PTSS through shame and guilt. However, though directly associated with more PTG, mindfulness could also negatively predict PTG by evoking less guilt. Mindfulness can be a way to cope with traumatic experiences and related psychological consequences. However, although mindfulness can reduce PTSS by suppressing negative trauma-related shame and guilt, it can also limit the realization of PTG by inhibiting the adaptive sides of these emotions.

Passing tests and using one's attitude to help patients overcome their pathogenic feelings of guilt and shame

Guilt and shame are emotions that, albeit subjectively negative, help humans adapt to their social environment. However, in some cases, there are pathogenic beliefs, shaped over the lifespan that sustain them and make them a source of psychopathological suffering. In this paper we will first briefly show how Control-Mastery Theory (CMT) considers several types of pathogenic beliefs shaped by traumatic experiences that underly chronic feelings of guilt and shame. We then focus on a clinical case of Livia, a 28 year-old woman with relational and academic problems suffering mainly from two such types of pathogenic beliefs: burdening guilt and disloyalty guilt. We describe how a) Livia was driven by adverse and traumatic experiences to form some of these pathogenic beliefs, b) how she tested the therapist in order to discover whether he would disconfirm these beliefs, and c) how the therapist was able to successfully pass these tests and provide her with new and healthier interpersonal experiences. The case of Livia will highlight therapists' ability to accurately formulate patients' goals, pathogenic beliefs-including types of guilt- and shame-related beliefs-and traumas. Moreover, the case will illustrate how therapists can pass patients' tests and adopt the right attitude to help patients disprove their pathogenic beliefs and overcome problematic experiences of guilt and shame.

Unlocking the past: efficacy of guided self-compassion and benefit-focused online interventions for managing negative personal memories

Positive reappraisal strategies have been found to reduce negative affect following the recall of negative personal events. This study examined the restorative effect of two mood-repair instructions (self-compassion vs benefit-focused reappraisal) and a control condition with no instructions following a negative Mood Induction Procedure by using the guided recall of a negative autobiographical event. A total of 112 university students participated in the online study (81% women, Mage: 21.0 years). Immediately following the negative memory recall, participants were randomised to each condition [(self-compassion: n = 36, benefit-focused: n = 39) or a control condition (n = 37)]. Repeated measures ANOVAs 3 (Repair condition) × 3 (Time of mood assessment: pre-recall, post-recall, post-regulation) showed that, as expected, negative mood (sadness, shame, and guilt) worsened significantly after the guided recall in all groups (p < .001). After the mood-repair intervention, participants in the self-compassion and benefit-focused conditions showed a significant reduction in negative mood (p < .019), while such improvement was not observed in the control group. Self-compassion and benefit-focused reappraisal functioned similarly as mood repair strategies after experiencing negative affect induced by the recall of negative personal memories. Implications in the context of autobiographical memory biases are discussed.

Dual Effects of Self-Compassion on Posttraumatic Stress Symptoms and Posttraumatic Growth: The Roles of Trauma-Related Shame and Guilt

Previous studies have shown that self-compassion can alleviate posttraumatic stress symptoms (PTSS) and promote posttraumatic growth (PTG). However, only a few studies explored the dual effects of its positive and negative components on PTSS and PTG. Also, the emotional mechanisms between self-compassion and PTSS/PTG remain unclear. Thus, with the three-wave longitudinal design, we examined the mediating role of trauma-related shame and guilt between self-compassion and PTSS/PTG among traumatized Chinese college students. 782 Chinese college students (467 females; Mage = 18.98, SD = 1.37) who had experienced traumatic events within the previous six months of the initial assessment were included in the study. In the direct effect model, compassionate self-responding (CSR) negatively predicted PTSS and positively predicted PTG. In contrast, uncompassionate self-responding (USR) positively predicted both PTSS and PTG. In the indirect model, CSR negatively predicted PTSS through trauma-related shame and guilt, but also negatively predicted PTG through trauma-related guilt. USR positively predicted PTSS through trauma-related shame and guilt and positively predicted PTG through trauma-related guilt. Thus, CSR can benefit posttraumatic college students by alleviating PTSS and promoting PTG, and USR may also have an adaptive side. Still, we should focus on the maladaptive and adaptive sides of trauma-related emotions in the intervention of posttraumatic college students.

Non-fear emotions in changes in posttraumatic stress disorder symptoms during treatment

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) is not only associated with fear but also with other emotions. The present study aimed to examine if changes in shame, guilt, anger, and disgust predicted changes in PTSD symptoms during treatment, while also testing if PTSD symptoms, in turn, predicted changes in these emotions.

METHODS

Participants (N = 155) with childhood-related PTSD received a maximum of 12 sessions of eye movement desensitization and reprocessing or imagery rescripting. The data was analyzed using Granger causality models across 12 treatment sessions and 6 assessment sessions (up until one year after the start of treatment). Differences between the two treatments were explored.

RESULTS

Across treatment sessions, shame, and disgust showed a reciprocal relationship with PTSD symptoms, while changes in guilt preceded PTSD symptoms. Across assessments, anger was reciprocally related to PTSD, suggesting that anger might play a more important role in the longer term.

LIMITATIONS

The individual emotion items were not yet validated, and the CAPS was not administered at all assessments.

CONCLUSIONS

These findings partly differ from earlier studies that suggested a unidirectional relationship in which changes in emotions preceded changes in PTSD symptoms during treatment. This is in line with the idea that non-fear emotions do play an important role in the treatment of PTSD and constitute an important focus of treatment and further research.

Problematic anger among military personnel after combat deployment: prevalence and risk factors

BACKGROUND

Problematic anger, characterized by excessive frequency, intensity, and duration of anger which causes substantial emotional distress and functional interference, poses a marked challenge in military populations. Despite its importance, research on this topic is limited. This study contributes to the literature by exploring problematic anger in a large sample of Norwegian military personnel who served in NATO missions in Afghanistan.

METHODS

All Norwegian military personnel who deployed to Afghanistan between 2001 and 2020 were sent a link to a cross-sectional web-based survey by the Joint Medical Services of the Norwegian Armed Forces in 2020. A total of 6205 individuals (response rate: 67.7%) participated. The cross-sectional survey assessed problematic anger, mental and physical health, war zone stressor exposure, and quality of life.

RESULTS

Overall, 8.4% of participants reported problematic anger. Mental health disorders, deployment-related shame and guilt, chronic pain, and challenges with the military-to-civilian transition were independently associated with problematic anger. Both staying in service and maintaining a part-time connection with the military as a reservist mitigated the risk of problematic anger after deployment, compared to complete separation from military service.

CONCLUSION

Findings demonstrate a sizeable prevalence of problematic anger among veterans of combat deployments. Given the associations between problematic anger and mental health disorders, chronic pain, and transition challenges, interventions designed to mitigate problematic anger need to be multi-faceted, including the possibility of maintaining an ongoing connection to military service. By reducing the risk of problematic anger, occupational, interpersonal and health outcomes may be improved for service members. Future research should examine the impact of problematic anger on adjustment over time, prevention strategies, and problematic anger in other high-risk occupations.

A latent profile analysis of moral emotions following moral transgressions

OBJECTIVE

Moral transgressions (MTs), events that violate one's moral code, are associated with the moral emotions of guilt and shame. However, there may be different patterns by which people experience guilt and shame that affect distress following MTs.

METHOD

Undergraduates (N = 1371) exposed to an MT completed self-report assessments. This study used latent profile analysis (LPA) to examine profiles based on guilt cognitions, internalized shame, and distress in relation to a reported MT. Cognitive flexibility, years since the MT, and deliberate and intrusive rumination were examined as variables to determine how these factors predicted profile membership.

RESULTS

Results from the LPA revealed a three-profile solution: a low moral distress profile (n = 1002), a moderate moral distress profile (n = 262), and a shame prominent profile (n = 107). Results indicated that higher levels of deliberate and intrusive rumination and lower levels of cognitive flexibility significantly increased the likelihood of belonging to the moderate moral distress or shame prominent profiles compared to the low moral distress profile. Higher levels of intrusive rumination and lower levels of cognitive flexibility also significantly increased the likelihood of belonging to the shame prominent profile over the moderate distress profile.

CONCLUSION

Three different profiles emerged, with the shame prominent profile being driven primarily by internalized shame. Results suggest that intrusive rumination and cognitive inflexibility are risk factors to experiencing adverse responses to MTs.

The Centrality of Humiliation in Complex Posttraumatic Stress Disorder

Victims of traumatic events that involve repeated interpersonal aggression and low or no chance of escape frequently report intense Self-Conscious Emotions (SCEs), such as Shame, Guilt, and Humiliation. Humiliation is the reaction to a forced loss of status and is hypothesized to have unique contributions to the development and maintenance of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD). However, previous studies did not include humiliation or did not simultaneously probe the relative contribution of each SCE to posttraumatic symptoms. This study aimed to investigate the dynamics between specific SCEs and trauma-related symptomatology in the general population who suffered a form of complex trauma. Four hundred forty-nine people (77.11% women) exposed to domestic violence and sexual abuse answered an online survey. We investigated whether each emotion would accurately predict probable PTSD and CPTSD levels above the proposed cutoff. We estimated a network model to understand the dynamics of their interactions and whether the traumatic event type would moderate relationships between SCEs and posttraumatic stress symptoms, comparing networks of two types of complex trauma. No SCE predicted PTSD, but humiliation was a predictor of CPTSD while controlling for Shame and Guilt. Humiliation was also the most central SCE domain in the networks of both traumatic events. Our results stress the relevance of Humiliation to understanding posttraumatic stress symptoms and the necessity to consider humiliation when studying the emotional processing in complex trauma.

Randomized trial on the effects of an EMDR intervention on traumatic and obsessive symptoms during the COVID-19 quarantine: a psychometric study

Introduction

It has been suggested that the COVID-19 pandemic was a potentially traumatic occurrence that may have induced generalized anxiety and discomfort, particularly in susceptible populations like individuals with mental illnesses. The therapeutic approach known as eye movement desensitization and reprocessing (EMDR) has been shown to be successful in helping patients process traumatic events and restore wellbeing. Nevertheless, little is known about the precise processes through which EMDR fosters symptom recovery.

Methods

In order to disentangle these issues, we conducted a randomized controlled trial (ClinicalTrials.gov Identifier NCT06110702) with 107 participants who were selected from university hospitals as a sample of investigation. Random assignments were applied to the participants in order to assign them to the experimental and control groups. The experimental group, but not the control group, underwent an 8-week EMDR intervention. Body perception, disgust, and emotions of guilt and shame, as well as mental contamination and posttraumatic and obsessive-compulsive symptoms, were investigated before and after the EMDR intervention.

Results

The EMDR intervention was able to improve all of the variables investigated. Path analysis showed that body perception was able to predict both disgust and emotions of guilt and shame. Disgust was able to predict both mental contamination and obsessive-compulsive symptoms, while guilt and shame were able to predict post-traumatic symptoms.

Conclusions

EMDR is an effective therapy for the treatment of post-traumatic and obsessive symptoms that acts through the promotion of improvement of the emotions of guilt/shame and disgust, respectively. Implications for clinical practice are examined.

Clinical trial registration

https://www.clinicaltrials.gov, identifier NCT06110702.

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD

Background: Maladaptive trauma appraisal plays an important role in the development and maintenance of posttraumatic stress disorder (PTSD). While studies have demonstrated the effectiveness of exposure and cognitive treatments for PTSD symptomatology, the effect of such treatments on specific trauma appraisals is still not well understood.Objective: The study investigated the effect of an exposure and a cognitive restructuring internet-based treatment on specific trauma appraisals in Arabic-speaking participants with PTSD.Method: 334 participants received either an exposure (n = 167) or a cognitive restructuring (n = 167) internet-based treatment. PTSD symptom severity (PCL-5) and specific trauma appraisals (TAQ) were assessed at pre- and post-treatment. Changes in specific trauma appraisals within and between the two treatments were analyzed using multi-group change modelling. Associations between changes in PTSD symptom severity and changes in trauma appraisals were evaluated using Pearson product-moment correlation. For both treatments, participants with versus without reliable improvement were compared regarding changes in specific trauma appraisals using Welch tests. Analyses were performed on 100 multiple imputed datasets.Results: Both treatments yielded significant changes in shame, self-blame, fear, anger, and alienation (all ps < .001). Changes in betrayal were only significant in the cognitive restructuring treatment (p < .001). There was no evidence of differences between treatments for any specific trauma appraisal. Changes in PTSD symptom severity were significantly associated with changes in trauma appraisals (all ps < .001). In both treatments, participants who experienced reliable improvement in PTSD symptom severity showed significantly larger pre- to post-treatment changes in specific trauma appraisals compared to those without reliable improvement. Again, differences in betrayal were only significant in the cognitive restructuring treatment.Conclusions: The findings indicate that both treatments are effective in reducing trauma appraisals in Arabic-speaking people with PTSD. Changes in trauma appraisal seem to be associated with changes in PTSD symptomatology.Trial registration: German Clinical Trials Register identifier: DRKS00010245.

The effects of a combination of cognitive interventions and loving-kindness meditations (C-METTA) on guilt, shame and PTSD symptoms: results from a pilot randomized controlled trial

Background: Trauma-related guilt and shame are crucial for the development and maintenance of PTSD (posttraumatic stress disorder). We developed an intervention combining cognitive techniques with loving-kindness meditations (C-METTA) that specifically target these emotions. C-METTA is an intervention of six weekly individual treatment sessions followed by a four-week practice phase.Objective: This study examined C-METTA in a proof-of-concept study within a randomized wait-list controlled trial.Method: We randomly assigned 32 trauma-exposed patients with a DSM-5 diagnosis to C-METTA or a wait-list condition (WL). Primary outcomes were clinician-rated PTSD symptoms (CAPS-5) and trauma-related guilt and shame. Secondary outcomes included psychopathology, self-criticism, well-being, and self-compassion. Outcomes were assessed before the intervention phase and after the practice phase.Results: Mixed-design analyses showed greater reductions in C-METTA versus WL in clinician-rated PTSD symptoms (d = -1.09), guilt (d = -2.85), shame (d = -2.14), psychopathology and self-criticism.Conclusion: Our findings support positive outcomes of C-METTA and might contribute to improved care for patients with stress-related disorders. The study was registered in the German Clinical Trials Register (DRKS00023470).

What will others think of me? The longitudinal association between trauma-related shame and guilt and psychopathology after a terror attack

BACKGROUND

Trauma-related shame and guilt have been identified as important factors for mental health following interpersonal trauma. For survivors of terror and disasters, however, the role of shame and guilt remains largely unknown.

AIMS

To explore the long-term occurrence of trauma-related shame and guilt among survivors of a terror attack, and the potential importance of these emotions for mental health.

METHOD

A total of 347 survivors (48.7% female, mean age at the time of the attack: 19.25 years, s.d. = 4.40) of the 2011 massacre on Utøya island, Norway, participated in face-to-face, semi-structured interviews. Trauma-related shame and guilt were measured with items from the Shame and Guilt After Trauma Scale at 2.5 and 8.5 years post-terror attack. Post-traumatic reactions and anxiety/depression at 8.5 years post-terror attack were measured with the University of California at Los Angeles PTSD Reaction Index and the Hopkins Symptom Checklist-25, respectively. Associations between trauma-related shame/guilt and post-trauma psychopathology were analysed by multiple linear regressions.

RESULTS

Trauma-related shame and guilt were prevalent among survivors at both 2.5 and 8.5 years post-terror attack. In unadjusted analyses, shame and guilt, at both time points, were significantly associated with post-traumatic stress reactions and anxiety/depression. Shame remained significantly associated with mental health when adjusted for guilt. Both earlier and current shame were uniquely related to mental health.

CONCLUSIONS

Trauma-related shame and guilt may be prevalent in survivors of mass trauma several years after the event. Shame, in particular, may play an important role for long-term mental health. Clinicians may find it helpful to explicitly address shame in treatment of mass trauma survivors.

Guilt-and Shame-Proneness, Birth-related Post-traumatic Stress and Post-Traumatic Growth in Women with Preterm Birth

Mothers of premature infants are at high risk of experiencing birth trauma and poor postpartum mental health. However, for some, this experience can lead to personal growth. This study examines Lithuanian women with preterm births, where birth-related PTSD is notably higher despite a lower preterm birth rate. Given the common emotional responses of guilt and shame, we explore whether proneness to these emotions moderates the relationship between birth-related PTSD and post-traumatic growth. A cross-sectional study was conducted using an anonymous e-survey to collect data. Women (N = 79) who experienced a preterm birth during 2020 to 2021 participated in the study at least 2 months postpartum, completing the City Birth Trauma Scale (City BiTS), the Guilt and Shame Proneness Scale (GASP), and the Post Traumatic Growth Inventory (PTGI). The relationship between birth-related post-traumatic stress and post-traumatic growth was assessed using linear regression, while the roles of guilt and shame proneness in this relationship were evaluated using moderated regression. The results showed that higher birth-related post-traumatic stress symptoms were associated with greater post-traumatic growth. However, proneness to shame-related negative self-evaluation weakened this relationship, particularly in women with very preterm births. These findings suggest that trauma models should incorporate the moderating role of shame in recovery outcomes. Women with very preterm births who are prone to shame may require more focused attention from healthcare specialists, with targeted interventions to address these emotional challenges and enhance post-traumatic growth. Additionally, policy initiatives should prioritize support programs tailored to the unique psychological needs of these women.

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

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. Women completed baseline and twice-daily assessments of MC and symptoms of PTSD over a 2-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. 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. 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.

Effects of digital psychological interventions on physical symptoms in cancer patients: A systematic review and meta-analysis

PURPOSE

This meta-analysis was to assess the efficacy of digital psychological interventions to improve physical symptoms (i.e., fatigue, pain, disturbed sleep, and physical well-being) among cancer patients, as well as to evaluate the variables that possibly moderate intervention effects.

METHODS

Nine databases were searched for the literature up to February 2023. Two reviewers independently conducted a quality assessment. Effect sizes were reported as the standardized mean difference (Hedge's g) and estimated using a random-effects model.

RESULTS

The meta-analysis included 44 randomized clinical trials comprising 7200 adults with cancer. Digital psychological interventions were associated with significant improvements in short-term fatigue (g = -0.33; 95% CI, -0.58 to -0.07) and disturbed sleep (g = -0.36; 95% CI, -0.57 to -0.15), but with non-significant changes in pain (g = -0.23; 95% CI, -0.68 to 0.21) and physical well-being (g = 0.31; 95% CI, -0.18 to 0.80). Additionally, no alleviation in long-term physical symptoms was observed. In subgroup analysis, results suggest that the country significantly moderated the effectiveness of digital psychological interventions in alleviating fatigue.

CONCLUSIONS

Digital psychological interventions can be effective for improving short-term fatigue and disturbed sleep in patients with cancer. Clinicians could consider digital psychological interventions as a possible and efficient addition to better manage some of the physical symptoms during and after cancer treatment.

Intraindividual variability and emotional change as predictors of sudden gains in imagery rescripting and EMDR for PTSD in adult survivors of childhood abuse

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post-traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre-registered randomized controlled trial (RCT) of eye-movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non-sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD.

Shame, self-disgust, and envy: An experimental study on negative emotional response in borderline personality disorder during the confrontation with the own face

Background

A markedly negative self-image and pervasive shame proneness have consistently been associated with borderline personality disorder (BPD). The present experimental study investigated the intensity of negative emotional responses with a focus on shame in BPD compared to healthy control persons (HCs) during an experimental paradigm promoting self-awareness, self-reflection, and self-evaluation. Furthermore, the relationship between levels of state shame during the experiment and shame proneness in BPD compared to HCs was examined.

Methods

A sample of 62 individuals with BPD and 47 HCs participated in the study. During the experimental paradigm, participants were presented with photos of (i) the own face, (ii) the face of a well-known person, and (iii) of an unknown person. They were asked to describe positive facets of these faces. Participants rated the intensity of negative emotions induced by the experimental task as well the pleasantness of the presented faces. Shame-proneness was assessed using the Test of the Self-Conscious Affect (TOSCA-3).

Results

Individuals with BPD experienced significantly higher levels of negative emotions than HCs both before and during the experimental task. While HC participants responded to their own face particularly with an increase in shame compared to the other-referential condition, the BPD patients responded above all with a strong increase of disgust. Furthermore, the confrontation with an unknown or well-known face resulted in a strong increase of envy in BPD compared to HC. Individuals with BPD reported higher levels of shame-proneness than HCs. Higher levels of shame-proneness were related to higher levels of state shame during the experiment across all participants.

Conclusion

Our study is the first experimental study on negative emotional responses and its relationship to shame proneness in BPD compared to HC using the own face as a cue promoting self-awareness, self-reflection, and self-evaluation. Our data confirm a prominent role of shame when describing positive features of the own face, but they emphasize also disgust and envy as distinct emotional experience characterizing individuals with BPD when being confronted with the self.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

A brief measure of guilt and shame: validation of the Guilt and Shame Questionnaire (GSQ-8)

Background: Guilt and shame regulate basic human processes such as social cognition and relations. Both emotions are also involved in the aetiology and maintenance of trauma-related mental disorders such as posttraumatic stress disorder (PTSD). However, a concise scale that adequately captures these constructs is currently lacking, impeding research efforts to understand them more thoroughly.Objective: To this end, we developed the eight-item Guilt and Shame Questionnaire (GSQ-8) in English, German, and Dutch.Method: We examined the reliability and validity of the GSQ-8 in a clinical sample of adults seeking treatment for childhood-trauma-related posttraumatic stress disorder (n = 209), a sample of adults who had suffered at least one traumatic life event reporting different levels of PTSD symptoms (n = 556), and a non-clinical sample of adults (n = 156).Results: Theory-driven confirmatory factor analyses confirmed two correlated latent factors guilt and shame with four items for each factor. Across all samples, two-factor models yielded better model fit than one-factor solutions. Measurement invariance across the three samples, gender, and Dutch and German language was mostly established. Guilt and shame composite scores were associated with PTSD symptoms, depressive symptoms, life satisfaction, mental health-related quality of life, and self-blame, thus supporting scale validity. Importantly, both subscales predicted PTSD symptoms, depression, life satisfaction, and mental health-related quality of life over and above cognitions of self-blame.Conclusions: The GSQ-8 is a parsimonious, reliable, and valid tool to assess guilt and shame in clinical, sub-clinical, and non-clinical populations, allowing applications across a broad range of research questions.

The relationship of trauma-related guilt with PTSD symptoms in adult trauma survivors: a meta-analysis

Posttraumatic stress disorder (PTSD) is a severe condition that is associated with trauma-related guilt. We aimed at providing a comprehensive quantitative systematic review on the relationship between trauma-related guilt and adult PTSD. Database searches in Medline, PsycINFO, PTSDpubs and Web of Knowledge resulted in the inclusion of 163 eligible studies with a total of 35 020 trauma survivors. The studies reported on 157 cross-sectional and 19 longitudinal data points. Overall, we included 135 studies not included in previous meta-analyses. Random-effect models yielded a moderate cross-sectional correlation (r = 0.38, 95% CI 0.35-0.42, p < 0.001, I² = 90.3%) and a small to moderate predictive correlation (r = 0.21, 95% CI 0.13-0.29, p < 0.001, I² = 66.7%). The association appeared to be stable over time and was robust to sensitivity analyses. All symptom clusters significantly correlated with guilt. No effects were found for military v. civilian populations or clinical v. non-clinical samples. Effects were smaller for high-quality studies and larger for instruments based on DSM-5. Further significant moderators were type of guilt measure and trauma type. The largest association was found among participants reporting war-related trauma (r = 0.44, 95% CI 0.36-0.51) and the smallest among survivors of motor-vehicle accidents (r = 0.18, 95% CI 0.02-0.33). The results underpin the role of trauma-related guilt in the onset and maintenance of PTSD symptoms, which have important clinical implications. Future studies should further explore the change interactions of guilt and PTSD symptoms.

Guilt is effectively induced by a written auto-biographical essay but not reduced by experimental pain

Introduction

The aim of the present study was (1) to validate the method of guilt-induction by means of a written auto-biographical essay and (2) to test whether experimental pain is apt to alleviate the mental burden of guilt, a concept receiving support from both empirical research and clinical observation.

Methods

Three independent groups of healthy male participants were recruited. Group allocation was not randomized but within group pain/sham administration was counterbalanced over the two test-days. Groups were tested in the following consecutive order: Group A: guilt induction, heat-pain/sham, N = 59; Group B: guilt induction, cold-pressure-pain/sham, N = 43; Group C: emotionally neutral induction, heat-pain/sham, N = 39. Guilt was induced on both test-days in group A and B before pain/sham administration. Visual analog scale (VAS) guilt ratings immediately after pain/sham stimulation served as the primary outcome. In a control group C the identical heat-pain experiment was performed like in group A but a neutral emotional state was induced.

Results

A consistently strong overall effect of guilt-induction (heat-pain: p &lt; 0.001, effect size r = 0.71; CPT-pain p &lt; 0.001, r = 0.67) was found when compared to the control-condition (p = 0.25, r = 0.08). As expected, heat- and cold-pressure-stimuli were highly painful in all groups (p &lt; 0.0001, r = 0.89). However, previous research supporting the hypothesis that pain is apt to reduce guilt was not replicated.

Conclusion

Although guilt-induction was highly effective on both test-days no impact of pain on behavioral guilt-ratings in healthy individuals could be identified. Guilt induction per se did not depend on the order of testing. The result questions previous experimental work on the impact of pain on moral emotions.

Laboratory models of post-traumatic stress disorder: The elusive bridge to translation

Post-traumatic stress disorder (PTSD) is a debilitating mental illness composed of a heterogeneous collection of symptom clusters. The unique nature of PTSD as arising from a precipitating traumatic event helps simplify cross-species translational research modeling the neurobehavioral effects of stress and fear. However, the neurobiological progress on these complex neural circuits informed by animal models has yet to produce novel, evidence-based clinical treatment for PTSD. Here, we provide a comprehensive overview of popular laboratory models of PTSD and provide concrete ideas for improving the validity and clinical translational value of basic research efforts in humans. We detail modifications to simplified animal paradigms to account for myriad cognitive factors affected in PTSD, which may contribute to abnormalities in regulating fear. We further describe new avenues for integrating different areas of psychological research underserved by animal models of PTSD. This includes incorporating emerging trends in the cognitive neuroscience of episodic memory, emotion regulation, social-emotional processes, and PTSD subtyping to provide a more comprehensive recapitulation of the human experience to trauma in laboratory research.

Attentional bias toward health-threat in health anxiety: a systematic review and three-level meta-analysis

Attentional bias toward health-threat may theoretically contribute to the development and maintenance of health anxiety, but the empirical findings have been controversial. This study aimed to synthesize and explore the heterogeneity in a health-threat related attentional bias of health-anxious individuals, and to determine the theoretical model that better represents the pattern of attentional bias in health anxiety. Four databases (Web of Science, PubMed, PsycINFO, and Scopus) were searched for relevant studies, with 17 articles (N = 1546) included for a qualitative review and 16 articles (18 studies) for a three-level meta-analysis (N = 1490). The meta-analytic results indicated that the health anxiety group, compared to the control group, showed significantly greater attentional bias toward health-threat (g = 0.256). Further analyses revealed that attentional bias type, paradigm, and stimuli type were significant moderators. Additionally, compared to the controls, health-anxious individuals displayed significantly greater attention maintenance (g = 0.327) but nonsignificant attention vigilance to health-threat (g = -0.116). Our results provide evidence for the attention maintenance model in health-anxious individuals. The implications for further research and treatment of elevated health anxiety in the context of coronavirus disease-2019 (COVID-19) were also discussed.