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Posttraumatic stress disorder (PTSD) is one of the most prevalent mental health disorders among US veterans (Magruder et al., 2005) and is associated with emotion dysregulation (i.e., an inability to effectively respond to emotional experiences; Gratz & Roemer, 2004). For example, emotion dysregulation has been identified as a developmental predictor of chronic PTSD (Pencea et al., 2020). Additionally, improvements in emotion dysregulation have corresponded with reductions in PTSD symptoms (Price et al., 2006) and emotion dysregulation has mediated reductions in PTSD severity over the course of Prolonged Exposure (PE; McLean et al., 2019). However, it is unclear if specific emotions play a role in this relationship. 

Shame, a negative evaluative emotion about oneself, is commonly associated with the development, maintenance (López-Castro et al., 2019), and severity (Cunningham et al., 2018) of PTSD, as well as positively associated with emotion dysregulation (Paulus et al., 2016). Shame may be particularly problematic for combat veterans suffering from PTSD. Moral injury, or the psychological suffering that follows actions, inaction, or events that transgress deeply held moral beliefs, is commonly observed in combat veterans and situates shame as one of the primary mechanisms of moral injury development (Frankfurt & Frazier, 2016). 

Notably, shame may be critical in determining the effect of emotion dysregulation on PTSD symptoms in this population. Specifically, previous research found that emotion dysregulation had no influence on PTSD severity among combat veterans with high levels of shame upon entering treatment (Puhalla et al., 2021). Moreover, emotional awareness (a component of emotion regulation) predicted lower PTSD severity for veterans with low levels of shame, but greater PTSD severity for veterans with high levels of shame. This finding suggests that shame may play an important role within the relationship between emotion dysregulation and PTSD. 
Our study examined how changes in shame and emotion dysregulation affected PTSD symptom improvement among combat veterans and whether shame acted as a mediator between changes in emotion dysregulation and PTSD symptoms in response to residential treatment. Within the residential program, veterans engaged in individual and group therapy, with 74% agreeing to an EBP for PTSD (e.g., Cognitive Processing Therapy [CPT; Resick et al., 2016] or PE; Foa et al., 2019).

Using self-report data from 43 male combat veterans who completed the residential program, we found that reductions in emotion dysregulation and shame were associated with reductions in PTSD symptoms over the course of treatment. Additionally, we found that shame significantly mediated the relationship between emotion dysregulation and PTSD symptoms.

Teaching emotion regulation techniques can be a highly effective skill for many psychiatric disorders. However, our data suggests that for combat veterans receiving an EBP in residential treatment for PTSD, these improvements are partially explained by reducing shame. This reduction of shame may occur several ways. For example, in CPT, shame may be addressed through the processing of the trauma and through Socratic dialogue which can assist in challenging shameful beliefs. Further, it is possible that as shame decreases, individuals can minimize the use of maladaptive coping strategies (e.g., emotional avoidance, substance use). This may be conducted through PE and group programing, as it encourages approach over avoidance. Finally, adaptive, skills-based strategies (i.e., DBT skills) may only be effective in reducing PTSD symptoms if shame is targeted and reduced among this population, as combat veterans may continue to utilize maladaptive strategies over adaptive ones if they have strong negative beliefs about themselves (e.g., “I am a monster, I am broken”) and potentially feel they do not deserve to get better (e.g., “I deserve this for who I am and what I did”). 

Altogether, our findings show the importance of reducing shame to alleviate PTSD symptoms. Importantly, evidence-based treatment in the context of residential programming may provide a framework for combat veterans to address shame through exposure, cognitive restructuring, and normalization through interacting with peers.


Reference Article 

Puhalla, A.A., Flynn, A.J., & Vaught, A.S. (In Press). Shame as a mediator in the association between emotion dysregulation and posttraumatic stress disorder symptom reductions among combat veterans in a residential treatment programJournal of Traumatic Stress

Discussion Questions

  1. What residential treatment factors may have contributed to the study findings?
  2. Why may addressing shame be especially important for combat veterans with PTSD?
  3. How may these findings have differed with other PTSD samples with different characteristics (e.g., female, non-combat veterans, community PTSD)?

About the Authors

Aidan_Flynn_headshot.jpgAidan Flynn, M.S., is a research technician at the Coatesville Veterans Affairs Medical Center and a prospective applicant to clinical psychology PhD programs. Aidan’s research interests include studying the cognitive and emotion regulation processes involved in psychopathology, especially anxiety disorders and PTSD.

Alexander-Puhalla.jpgAlexander Puhalla, Ph.D., is a post-doctoral researcher at the Cincinnati Veterans Affairs Medical Center. Dr. Puhalla’s research interests include studying cognitive-affective mechanisms of change within PTSD treatment, as well as developing novel ways to improve PTSD treatment outcomes. Additionally, Dr. Puhalla has a strong interest in how physiology impacts PTSD symptoms and externalizing behaviors broadly. 

Amanda S. Vaught, Psy.D., is the Director of Psychology Training and DBT team leader at the Coatesville Veterans Affairs Medical Center. She is also a VISN 4 CPT trainer and consultant.  Dr. Vaught’s research interests include exploratory research on treatment-seeking Veterans, specifically related to PTSD maintenance, treatment outcome, eating disorders, emotion regulation, and Veteran suicide.

References Cited

Cunningham, K. C., Davis, J. L., Wilson, S. M., & Resick, P. A. (2018). A relative weights comparison of trauma‐related shame and guilt as predictors of DSM‐5 posttraumatic stress disorder symptom severity among US veterans and military members. British Journal of Clinical Psychology57, 163-176.

Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – therapist guide (2nd ed.). Oxford University Press.
Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology28, 318-330.

Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26, 41-54. 

López‐Castro, T., Saraiya, T., Zumberg‐Smith, K., & Dambreville, N. (2019). Association between shame and posttraumatic stress disorder: A meta‐analysis. Journal of Traumatic Stress32, 484-495.

Magruder, K. M., Frueh, B. C., Knapp, R. G., Davis, L., Hamner, M. B., Martin, R. H., ... & Arana, G. W. (2005). Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. General Hospital Psychiatry27, 169-179.

McLean, C. P., Zang, Y., Gallagher, T., Suzuki, N., Yarvis, J. S., Litz, B. T., Mintz, J., Young-McCaughan, S., Peterson, A.L., Foa, E.B., & STRONG STAR Consortium. (2019). Trauma-related cognitions and cognitive emotion regulation as mediators of PTSD change among treatment-seeking active-duty military personnel with PTSD. Behavior Therapy, 50, 1053-1062.

Paulus, D. J., Vanwoerden, S., Norton, P. J., & Sharp, C. (2016). Emotion dysregulation, psychological inflexibility, and shame as explanatory factors between neuroticism and depression. Journal of Affective Disorders, 190, 376-385. 

Pencea, I., Munoz, A. P., Maples-Keller, J. L., Fiorillo, D., Schultebraucks, K., Galatzer-Levy, I., Rothbaum, B.O., Ressler, K.J., Stevens, J.S., Michopoulos, V., & Powers, A. (2020). Emotion dysregulation is associated with increased prospective risk for chronic PTSD development. Journal of Psychiatric Research, 121, 222-228.

Price, J. L., Monson, C. M., Callahan, K., & Rodriguez, B. F. (2006). The role of emotional functioning in military-related PTSD and its treatment. Journal of Anxiety Disorders20, 661-674.

Puhalla, A.A., Flynn, A.J., & Vaught, A.S. (2021). Shame as a moderator between emotion dysregulation and posttraumatic stress disorder severity among combat veterans seeking residential treatment. Journal of Affective Disorders, 283, 236-242.

Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. The Guilford Press.