Shame on display
In a broadcast interview in early 2025, US President Donald Trump accused Ukrainian President Volodymyr Zelensky of being disrespectful and ungrateful, citing US support to Ukraine. The moment was tense and quickly went viral. This exchange illustrates how shame operates as a publicly shaped phenomenon. In a busy emergency room, a junior doctor makes a minor error during a routine case. The supervisor reprimands the doctor harshly in front of the team. The junior freezes, cheeks flushed, avoids eye contact and remains silent for the rest of the shift. They begin to second-guess decisions, avoid asking questions and consider leaving the programme. An early-career entrepreneur from a minority culture in the USA who had helped shape a novel invention from the outset was unexpectedly removed from a principal role by another entrepreneur. Hurt and confused, she wrote to the company to ask why. A senior team member replied in a reprimanding tone, saying her request for clarification was inappropriate: too emotional, too personal and too aggressive; and that its cultural tone was incompatible with the company’s standards. The exchange left the entrepreneur feeling deeply ashamed, blamed and hopeless, as her appeal for fairness seemed to backfire, exposing her to harsh negative judgement from the group. Examples such as public criticism or scapegoating illustrate how shame can undermine learning, confidence and mental health. While ordinary shame serves to regulate social behaviour, its intensified form can be weaponised through humiliation and stigma, deepening feelings of inadequacy and vulnerability.
Meaning and dimensions of shame
Shame is a self-conscious emotion involving self-reflection and negative self-evaluation, Reference Sznycer1 frequently associated with stigma. It is an intensely unpleasant feeling of being exposed as flawed, triggered by real or anticipated criticism. Unlike guilt, which focuses on actions (‘I did something wrong’) and often leads to repair, shame targets the self (‘I am a bad person’) and tends to provoke withdrawal. Shame is oriented more to moral faults and public failures, emphasising others’ negative evaluations. While other-directed emotions such as empathy or envy involve social comparisons, shame reflects direct evaluations of personal identity by oneself and others. Reference Baez, García, Santamaría-García, Ibáñez, Sedeño and García2 In regulated doses, shame serves social functions by discouraging norm violations and reinforcing ethical standards, fostering trust and cooperation. In supportive environments, shame promotes accountability and moral development. However, when chronic, excessive or weaponised, shame shifts from regulation to harm.
Brain and body dimensions
Shame engages brain regions involved in self-focus, self and social evaluation and moral reasoning (dorsolateral, ventrolateral and dorsomedial prefrontal cortex, anterior insula, posterior cingulate, parahippocampal and sensorimotor cortex) (Fig. 1(a)). This pattern highlights the cognitive and emotional complexity of shame, and its strong focus on the self and perceived social failure. Reference Bastin, Harrison, Davey, Moll and Whittle3 Described brain networks support both the adaptive function – regulating behaviour to avoid social devaluation, Reference Sznycer1 and the excessive emotional burden.
The dimensions and continuum of shame. (a) The multidimensional nature of shame across four interacting dimensions: brain and body, psychological, sociocultural and institutional. The left side illustrates neurophysiological pathways activated during shame and stress responses, highlighting predictive processing between cortical and limbic areas and peripheral systems via the autonomic and gut–brain axes. Shame’s psychological dimension involves self-conscious emotions, internalised stigma and unresolved trauma. Socioculturally, it is shaped by social norms, public scrutiny and collective narratives. Institutionally, shame is reinforced through blame cultures in systems that include healthcare, education and leadership. (b) A continuum of shame expressions, ranging from adaptive to maladaptive, along with strategies for intervention and repair. These evidence-based approaches include trauma-informed care, emotional literacy, accountable leadership and culturally responsive reframing. This integrative framework repositions shame – from a hidden burden to a target for systemic awareness and healing. PFC, prefrontal cortex; AI, anterior insula; PCC, posterior cingulate cortex; PHC, parahippocampal cortex; SMC, sensorimotor cortex; HPA, hypothalamic–pituitary–adrenal.
Shame and guilt partially share overlapping circuits, such as the medial prefrontal cortex, anterior insula and posterior cingulate cortex. However, shame engages regions including the dorsal medial prefrontal cortex and anterior insula more strongly, reflecting its emphasis on social threat and bodily self-awareness. Reference Baez, García, Santamaría-García, Ibáñez, Sedeño and García2,Reference Bastin, Harrison, Davey, Moll and Whittle3 Guilt, in contrast, shows greater involvement of the ventromedial prefrontal cortex and subgenual anterior cingulate. Despite these subtle distinctions, the neural representation of shame and guilt is neither highly specific nor modular; instead, it is dynamic and shaped by individual, cultural and contextual factors.
Shame has distinct physiological effects across bodily systems (Fig. 1(a)). It activates the sympathetic nervous system, increasing heart rate, blood pressure and skin conductance. Intense or chronic shame may trigger a parasympathetic ‘freeze’ response, with reduced heart rate variability and emotional numbing. It is linked to elevated cortisol (via the hypothalamic–pituitary–adrenal axis), reflecting prolonged stress and reduced vagal tone, which impairs emotional regulation and social engagement. Reference Baez, García, Santamaría-García, Ibáñez, Sedeño and García2,Reference Bastin, Harrison, Davey, Moll and Whittle3 Gastrointestinal symptoms such as nausea or stomach tightness point to gut–brain axis involvement. When persistent, shame may drive inflammation and metabolic dysregulation, contributing to depression, obesity and autoimmune conditions.
Psychological dimensions
Psychologically, shame involves intense feelings of worthlessness and a desire to hide or withdraw. Shame regulates behaviour via self-evaluation, fear of rejection, sensitivity to social comparison and negative self-beliefs. Shame often arises from internalised stress or trauma, particularly in early relationships that undermine confidence. Adverse childhood experiences such as abuse, neglect, emotional invalidation or bullying can lead to internalised shame. Shame is associated with secrecy and isolation, and can trigger explosive and angry outbursts and lead to risky behaviours. Shame is difficult to confront because it erodes interpersonal connections, Reference Sznycer1 promoting maladaptive coping strategies including perfectionism and emotional and behaviour dysregulation. Not all shame is pathological. Normative shame can regulate social behaviour and moral learning, whereas pathological shame involves persistent self-devaluation, rigidity or trauma-based internalisation that generalises across contexts and impairs functioning.
Social, cultural, political and institutional dimensions
Sensitivity to shame varies across individuals, shaped by temperament, attachment history, early life experiences and cultural socialisation. Within organisations, rigid hierarchies and public evaluation can heighten shame reactivity; supportive leadership, confidential feedback and error-reporting systems focused on learning processes, growth of mindset-framing (‘skills are improvable’) and self-determination skills to support autonomy, competence, relatedness and motivation, rather than blame–shame situations, can buffer these effects. From an evolutionary perspective, shame probably emerged as a regulatory mechanism that reinforces social cohesion, shaping social behaviours and stimulating conformity to collective norms. Reference Landers and Sznycer4 Experiencing shame following social transgressions discourages behaviours detrimental to group harmony, thus minimising conflict, avoiding social exclusion and enhancing group stability and trust. Reference Landers and Sznycer4
At a societal level, shame plays a role in maintaining social order, norms and morality. Reference Schaumberg and Skowronek5 Societies often differ regarding the role of shame in their culture. In shame-oriented cultures there is a pronounced emphasis on collective conformity, moral standards and avoiding public disgrace. Reference Schaumberg and Skowronek5 Conversely, in Western contexts, shame can emphasise individual responsibility, private moral accountability and an internalised conscience. Thus, shame not only guides individual behaviour but also reflects and reinforces broader cultural values. Reference Matos, Galhardo, Moura-Ramos, Steindl, Bortolon and Hiramatsu6 Collectivist societies such as Japan and Singapore have reported higher levels of external shame. Individualistic cultures such as Australia and France have shown the pre-eminence of personal standards and internal evaluations. Reference Matos, Galhardo, Moura-Ramos, Steindl, Bortolon and Hiramatsu6 Understanding cultural nuances is crucial for developing situated psychological assessments and interventions.
Politically, shame often enforces social conformity, stigmatises behaviours or groups and shapes collective sentiments. Shame has reinforced public accountability among political figures. However, recent shifts toward a ‘post-shame’ culture have eroded these norms. Countries frequently use ‘naming and shaming’ to address human rights violations. Domestically, shame can be weaponised to delegitimise opponents, fuel identity politics and deepen polarisation.
Shame can also operate at the intersection of multiple social identities, compounding the effects of stigma and systemic inequities. Individuals from marginalised groups – such as racial and ethnic minorities, lesbian, gay, bisexual, transgender and queer or questioning individuals, or women in male-dominated academic environments – may experience shame interpersonally and social exclusion. Across societies, shame is often invoked to preserve traditions or enforce role expectations – for instance, concealing mental illness to ‘protect’ family honour or sanctioning women who defy gender norms. Such practices can sustain group identity while perpetuating stigma and exclusion.
Shame and its impact on health and well-being
Shame can be both a cause and consequence of mental illness. It has been poorly addressed by mental health professionals, primarily due to a lack of awareness. Increased levels of shame have been linked to social anxiety, Reference Michail and Birchwood7 major depression, substance abuse, eating disorders, Reference Matos, Coimbra and Ferreira8 body dysmorphic disorder, Reference Matos, Coimbra and Ferreira8 body-focused repetitive behaviours, psychosis, Reference Michail and Birchwood7 post-traumatic stress disorder and suicide risk and despair. However, shame has rarely been explored as a driving factor for these conditions. When trauma underlies these disorders, addressing shame can bring therapeutic benefits.
People living with dementia often experience stigma and negative self-perceptions. Stigma can intensify shame, affecting not only people living with dementia but also their families, who may become secretive and fearful of discussing the illness. Shame and stigma frequently lead to social withdrawal, isolation and loneliness. In healthcare settings, shame experiences can happen to both patients and healthcare professionals. Reference Dolezal and Bynum9 In some cases, shame and anticipatory humiliation can lead to depression, anxiety and even suicide. For example, a nurse publicly criticised following a near-miss incident may internalise enduring shame, avoid help-seeking and eventually burn out, illustrating how acute interpersonal dynamics can result in chronic distress.
Shame can lead to work-related health and organisational burnout, which fosters stress, secrecy, withdrawal and absenteeism. Teaching by shaming still happens in medical education and PhD training settings. This practice is particularly harmful, contributing to mental health problems, increasing burnout and discouraging help-seeking when facing uncertainty.
How to deal with shame and its consequences
Recognising and working through shame with self-compassion, empathy and accountability can reduce harmful expressions and foster more adaptive emotions. The aim is not to eliminate shame, which is an inherent human emotional experience, but to mitigate its toxic forms and promote constructive reflection. In healthcare, psychological safety grows when fair, transparent learning cultures replace punitive or shaming practices.
There is a need to prevent shame-based practices and develop strategies for addressing these (Fig. 1(b)). The first step is to name it. Reference Dolezal and Bynum9 Shame is often hidden; ending this secrecy is essential. Mental health professionals need more knowledge and awareness about shame. Accepting shame and replacing its pathological versions with more adaptive emotions is the best way forward. Therapeutic approaches, therefore, focus on strengthening the capacity to bear shame, integrating it into self-understanding rather than seeking its removal. Therapeutic work is inherently relational: it helps individuals name exposure, mentalise others’ perspectives and rebuild connection while cultivating self-compassion within safe interpersonal contexts. This perspective echoes relational accounts emphasising that shame is repaired, not removed, through empathic engagement, with the discomfort of being seen and seeing oneself.
Leaders must recognise the dangers of shaming or humiliating others because it can harm mental health, hinder communication and raise organisational risks. Shame triggers withdrawal, hidden errors and unpredictability. In healthcare, pathological shame cultures block trust, creativity and openness; a no-blame-and-shame approach is required. Institutions should support both affected families and staff facing emotional distress from shame. Shame dynamics should be included in medical education to foster safe learning and prepare doctors. Building shame competence requires moving beyond individual awareness towards systemic change. Reference Dolezal and Bynum9 Building shame competence requires systemic change – creating environments that acknowledge shame with empathy, accountability and repair. Embedding this into healthcare leadership and culture promotes psychological safety and effective care.
Leveraging shame for positive change at individual and societal levels
Understanding shame from sociocultural, institutional and neuropsychological perspectives offers opportunities for personal growth and social transformation (Fig. 1(b)). By recognising shame’s roots in brain processes such as social evaluation and emotional regulation, targeted interventions can reduce pathological shame and promote mental health, resilience and self-compassion. Culturally aware approaches can better address shame-related stigma. Reframing shame in public discourse (from stigmatising to fostering empathy and accountability) can drive prosocial behaviour and civic responsibility. Public health and education efforts that leverage shame constructively can enhance social cohesion and promote compassionate, equitable policies. Thus, an integrated approach can significantly enhance shame-related dynamics at individual and societal levels.
Shame is a powerful emotion rooted in secrecy, often making us feel damaged and unworthy. Its impact spans psychological, neurocognitive, sociocultural and institutional domains. Addressing shame requires naming and understanding it; tracing its roots in trauma, early experiences and societal norms. Rather than seeing it as a personal flaw, we must treat shame as a public health and relational issue, calling for systemic, empathic and culturally sensitive responses. Building shame competence in education, healthcare and leadership can foster safer spaces for learning, healing and growth.
Author contributions
All authors meet International Committee of Medical Journal Editors criteria for authorship. B.L. and A.I. jointly conceived the idea for this article and led the drafting. S.B. and H.S.-G. contributed literature review, rewriting and examples. All authors critically revised the manuscript, approved the final version and are accountable for its integrity.
Funding
A.I. is supported by the Multi-Partner Consortium to Expand Dementia Research in Latin America (ReDLat), supported by the Fogarty International Center (FIC), the National Institutes of Health, the National Institute on Aging (nos R01 AG057234, R01 AG075775, R01 AG21051, R01 AG083799, CARDS-NIH 75N95022C00031), the Alzheimer’s Association (no. SG-20-725707), the Rainwater Charitable Foundation – The Bluefield Project to Cure FTD and the Global Brain Health Institute. A.I. is also supported by ANID/FONDECYT Regular (nos 1250091, 1210176, 1220995) and ANID/FONDAP/15150012. The contents of this publication are solely the authors’ responsibility and do not represent the official views of the above-named institutions.
Declaration of Interest
None.
Transparency declaration
The lead author affirms that this manuscript is an honest, accurate and transparent account of the work being reported, that no important aspects have been omitted and that any discrepancies from the planned work have been explained.
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