Beyond Self-Report: Measuring the Psychological Impact of Shame in Veterans with PTSD

Timothy McCoy, Ray Siddiqi, & Alexander Puhalla

July 7, 2026

Posttraumatic stress disorder (PTSD) is one of the most common forms of psychopathology that impacts U.S. veterans (American Psychiatric Association, 2013; Trivedi et al., 2015). Shame, an intense negative self-evaluation, involves thoughts like "I am broken" or "I am a failure" and has been shown to be especially problematic as it plays a role in the development, severity, and maintenance of PTSD symptomatology (Serfioti et al., 2024). Past research links shame to PTSD severity as well as suicidal ideation and aggression (Crocker et al., 2016; Cunningham, 2019). 

However, most prior work relies heavily on self-report measures, and while useful, the lack of physiological measures within this area of research limits our understanding of the physiological manifestation of shame. Furthermore, while subjective emotional responses to trauma recall have been studied, there has been very limited examination of how physiological regulation and recovery occur in real time during and after the experience of shame, which is highly relevant to exposure techniques commonly used in PTSD treatment. 

New Research

Our study examined the affective and physiological responses to both written and imaginal shame induction in 50 veterans who were attending a VA residential program. Participants underwent either written (Scheel et al., 2013) or imaginal (Cameron et al., 2020) shame inductions at random, with a baseline task preceding the induction and a natural recovery period afterwards. We predicted that heart rate (HR) and skin conductance response (SCR) (two objective measures of physiological reactivity) would rise during shame induction. Conversely, we predicted that respiratory sinus arrhythmia (RSA; an objective measure of physiological regulation) would decrease. Further, we predicted that negative self-evaluative emotions (NSEs, i.e., shame, guilt, embarrassment) would increase more than other emotions (i.e., anger, fear) during shame induction, and that NSEs would be associated with PTSD severity. 

We found that HR and SCR were both increased post-induction, while RSA was decreased. Furthermore, SCR and RSA did not shift significantly during the natural recovery period, but HR did significantly decrease. NSEs did increase more than other emotions during inductions, and NSEs were positively correlated with PTSD. Importantly, participants in the imaginal shame induction group demonstrated greater RSA withdrawal and NSE reactivity during the induction compared to participants in the written shame induction group. 

Clinical Implications

These findings have important clinical implications. First, veterans experiencing shame did not show typical physiological recovery patterns, evidencing continued dysregulation even after shame induction ended. Therefore, it may be beneficial for clinicians to consider scaffolding downregulation during shame-inducing exposure(s) and not assume the patient will downregulate without active intervention. This may be as simple as adding additional processing time or using directed Socratic Dialogue to find flexible responses to NSEs related to the exposure or the trauma itself. 

Second, a lack of parasympathetic recovery can lead to reliance on maladaptive coping strategies like avoidance and substance use, which can lead to increased aggression and irritability. These phenomena have important implications for treatment adherence.

Third, the current data indicate that the imaginal shame induction, as opposed to the written shame induction, elicited greater physiological reactivity. Importantly, the type of induction chosen within exposure therapy has clear weaknesses and strengths, such that one induction type may be preferred over the other, depending on the treatment approach. However, future studies are warranted to examine the physiological underpinnings of shame-related trauma.

Lastly, it may be beneficial to target shame's physiological components with approaches such as biofeedback, enabling veterans to self-regulate and remain engaged in treatments like cognitive processing therapy that primarily focus on cognitive-emotional processing. 

In sum, measuring shame's physical impact reveals that shame may contribute to sustained autonomic imbalance and perpetuate PTSD symptoms. Therefore, treatment approaches should consider both the emotional and physiological dysregulation that occurs, due to shame, within veterans with PTSD and not solely focus on the cognitive and emotional components of symptomatology. 

Discussion Questions

1. How might clinicians use this information to inform treatment decisions surrounding the use of imaginal versus written exposure, and what role does the endorsement of shame play in these decisions?
2. Using the current findings, how would the type of trauma possibly moderate the physiological findings, and how would this impact the choice of treatment?
3. How can we tease apart the impact of negative self-evaluative emotions broadly (e.g., shame, guilt, embarrassment), and how do we use the endorsement of these different emotions to guide clinical decision-making?

About the Authors

Reference Article

McCoy, T., Hughes, Anna F., Siddiqi, R., Bittner, J., & Puhalla, A.A. (2026). The physiological and affective mechanisms of shame among veterans with posttraumatic stress disorder symptoms. Journal of Traumatic Stress. https://doi.org/10.1002/jts.70075

References