To Trust is to Survive: Toward a Developmental Model of Moral Injury

Research on trauma- and stressor-related disorders has recently expanded to consider moral injury, or the harmful psychological impact of profound moral transgressions, betrayals, and acts of perpetration. Largely studied among military populations, this construct has rarely been empirically extended to children and adolescents despite its relevance in the early years, as well as youths' potentially heightened susceptibility to moral injury due to ongoing moral development and limited social resources relative to adults. Application of the construct to young persons, however, requires theoretical reconceptualization from a developmental perspective. The present paper brings together theory and research on developmentally-oriented constructs involving morally injurious events, including attachment trauma, betrayal trauma, and perpetration-induced traumatic stress, and describes how they may be integrated and extended to inform a developmentally-informed model of moral injury. Features of such a model include identification of potentially morally injurious events, maladaptive developmental meaning-making processes that underlie moral injury, as well as behavioral and emotional indicators of moral injury among youth. Thus, this review summarizes the currently available developmental literatures, identifies the major implications of each to a developmentally-informed construct of moral injury, and presents a conceptual developmental model of moral injury for children and adolescents to guide future empirical research.

Path to posttraumatic growth: The role of centrality of event, deliberate and intrusive rumination, and self blame in women victims and survivors of intimate partner violence

Increased interest in positive changes in the aftermath of traumatic events led researchers to examine assumptions about the process of posttraumatic growth (PTG). However, existing studies often use samples from mixed trauma survivors and investigate separate factors and their associations with growth. Therefore, the purpose of the current study was to examine the path from centrality of event to PTG involving intrusive and deliberate rumination and self-blame as a coping strategy in women survivors of intimate partner violence (IPV). The study sample consisted of 200 women with a history of IPV (ages 18–69, M = 44.79, SD = 12.94). Results of the path analysis indicated that higher centrality of event was related to higher levels of intrusive rumination which was positively related to self-blame and deliberate rumination eventually leading to PTG. Indirect effects from centrality of event to PTG through intrusive and deliberate rumination, and from intrusive to deliberate rumination through self-blame were examined. This study gave support to some theoretical assumptions of the process of PTG and pointed out problematic areas of investigation of coping strategies in this process.

Treatment for Moral Injury: Impact of Killing in War

Purpose of Review

Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior.

Recent Findings

In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition.

Summary

IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.

Longitudinal Investigation of Posttraumatic Growth in Female Survivors of Intimate Partner Violence: The Role of Event Centrality and Identity Exploration

The purpose of this study was to investigate the change in posttraumatic growth (PTG) of women survivors of intimate partner violence (IPV) in Lithuania, in relation to the centrality of traumatic experience, identity exploration, and time after exposure to violence. The longitudinal study sample consisted of 217 women who experienced IPV, recruited from women shelters, social support centers, and through counseling psychologists. In this sample the assessment instruments were administered three times during an 18-month period (at 6-month intervals). The results of the study revealed that PTG significantly increased over time for the women who experienced IPV more recently. Those women who experienced IPV more anciently reported higher PTG levels at the beginning of the study, but significant changes in PTG did not emerge. In addition, higher levels of PTG at the beginning of the study were positively associated with event centrality and identity exploration, meaning that those women who perceived their IPV experience as central to their identity and who explored possible identity choices were more likely to have higher levels of PTG at the beginning of the study. However, neither the centrality of the event nor the identity exploration was important for the change in PTG over the study period. Findings of this study highlighted the importance of the first 2-year period after the violence when the potential for PTG and its increase occurs. Limitations of the study and implications for future research are discussed.

Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers

IMPORTANCE

Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others.

OBJECTIVE

To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity.

RESULTS

A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07).

CONCLUSIONS AND RELEVANCE

This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.

The Role of Social Support in Identity Processes and Posttraumatic Growth: A Study of Victims of Intimate Partner Violence

The purpose of this study was to explore the role of social support for posttraumatic growth (PTG) and identity processes in a sample of 217 women victims of intimate partner violence (IPV), recruited from women shelters, social support centers, and through counseling psychologists. The results of the study highlight the important role of social support in seeking positive personal resolutions after experiencing traumatic events of IPV. It indicates that social support, but not social nonsupport, predicts higher levels of PTG and the development of new positive identities. In particular, social support was positively associated with the manifestation of all five identity processes, that is, with identification with commitment, commitment making, exploration in breadth, exploration in depth, and ruminative exploration. Furthermore, contextual and socioeconomic factors, such as time after last violence, relationships with the perpetrator, place of residence, education, and age of the victims of IPV were also related to identity processes. Severity of the violence, time after the last violence, education, and personal income were related to PTG. Thus, this study indicated that there are significant contextual and socioeconomic differences in the PTG and reconsideration of one's identity. Recommendations for practitioners and future research have been suggested.

Mini-review: A possible role for galanin in post-traumatic stress disorder

Several neuroendocrine systems have been implicated in post-traumatic stress disorder, including the mesocortical and mesolimbic dopamine, the norepinephrine, the β-endorphin, the serotonin, and the oxytocin systems. The interaction between these different systems remains, however, largely unknown and a generally accepted unifying theory is thus far lacking. In this review, we suggest that galanergic suppression of dopaminergic neurons in the ventral tegmental may constitute the missing link in a post-traumatic feedback loop. In addition, we address the literature on the negative cross-antagonism in this brain region between the galanin 1 and μ-opioid receptors, which suggests that behavioural patterns which stimulate β-endorphin, a natural μ-opioid receptors ligand, secretion may provide novel avenues for the treatment and prevention of PTSD, as well as for recruitment, training, and leadership processes in high-stress/high-risk professions such as the military, first responders and the police.

Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

A Pilot Study of a Moral Injury Group Intervention Co-Facilitated by a Chaplain and Psychologist

Moral injury, an experience of betrayal or transgression of moral values, continues to receive attention because of its associations with psychiatric disorders, including posttraumatic stress disorder and suicidality. There is growing recognition that moral injury may require novel interventions that involve religious or spiritual paradigms. This pilot study presents feasibility data and exploratory outcomes for 40 veteran participants across seven cohorts who participated in a novel 12-week moral injury group (MIG) over 35 months. The MIG was cofacilitated by a Veterans Affairs chaplain and psychologist and designed to reduce distress and improve functioning in individuals with histories of morally injurious experiences from military service. The intervention included a ceremony in which participants shared testimonies of their moral injury with the general public. Recruitment feasibility and retention were high, with participants completing an average of 9.45 (SD = 2.82) sessions of the 12-week group, and 32 participants (80.0%) attending nine or more sessions and the community healing ceremony. Exploratory analyses revealed medium effect sizes, ω² = 0.05-0.08, for reductions in depressive symptoms, improvements in psychological functioning, and self-compassion after the intervention, with small effect sizes, ω² = 0.03, in anticipated directions for personal growth and spiritual struggles. The results were not impacted by participant engagement in concurrent psychological treatments. Taken together, these findings support the feasibility of the MIG, the potential merit of an interdisciplinary approach to addressing moral injury, and justification for further research into the efficacy of this approach.

Mental disorders and medical conditions associated with causing injury or death: A population-based study

The aim of the present study is to examine mental disorders and medical conditions associated with causing harm to another person in the general adult population. The sample (n=22,138) was drawn from a cross-sectional survey designed to characterize mental health needs in France. Twelve-month DSM-IV axis I mental disorders and medical conditions, and lifetime occurrence of potentially traumatic events were assessed with the Composite International Diagnostic Interview-SF Overall, 2% (n=430) of the sample reported having injured or killed someone. Causing harm was associated with male gender, lower education level, and being unemployed. The great majority (85%) of those who caused harm had experienced two or more additional potentially traumatic events. When adjusting for gender, employment status, education and number of events experienced, causing harm was associated with certain anxiety disorders, drug dependence and lifetime suicide attempt but not with major depression or post-traumatic stress disorder. Furthermore, causing harm was not associated with medical conditions in multivariate analyses. These results highlight the need for clinicians to be particularly attentive to the psychological burden that may be experienced by those who have harmed or killed someone.

The Buffering Effect of Relationships on Combat Exposure, Military Performance, and Mental Health of U.S. Military Soldiers: A Vantage Point for CFTs

This study examined the role of cumulative combat experiences with regard to military performance and conduct and mental health among a sample of young soldiers from the Army STARRS dataset (N = 5,283). Higher levels of cumulative combat experiences were directly related to poorer performance and conduct and a greater likelihood of anxiety, depression, and post-traumatic stress disorder (PTSD). Military performance and conduct served as a linking mechanism between combat experiences and mental health. Using moderated mediation structural equation modeling, relationship disruptions were found to exacerbate the adverse effects of combat experiences; conversely, unit cohesion buffered the impact of combat experiences. Implications for military helping professionals include identifying leverage points for intervention, particularly strengthening the social connections of service members within and outside the military.

Outside the Military "Bubble": Life After Service for UK Ex-armed Forces Personnel

Military personnel who have seen active service can be affected by their experiences. Much of the literature on the mental and physical health battles faced by men and women who leave the Armed Forces is dominated by research in the United States (US) (1), and is particularly focused on exposure to deployment, combat conditions, and effects on mental health. Research in the United Kingdom (UK) tends to focus on depression or alcohol misuse and the impact these issues have on currently serving personnel. This study aimed to present UK veterans' first-hand experiences related to military service, access to and use of mental healthcare and interventions, and the impact of transition on the military family. Semi-structured interviews explored experiences of 30 participants (27 male, 3 female). Participants ranged in age from 26 to 92 years (M = 53.33), and across multiple war cohorts (from WWII to Iraq and Afghanistan). Data were analyzed using Thematic Analysis and Narrative Analysis. Findings show meaning-making from experiences of transition across veteran cohorts. Main themes were reasons for leaving Armed Forces, life outside the military, and mental health concerns after service. Subordinate themes additionally focused on evaluation of identity and mental health service provision. Future clinical research should include the experiences of UK serving personnel and the effects of pre-and post-military adversity, alongside the impact of deployment experiences. Interventions designed to address transition into life after service are discussed.

Moral Injury: An Integrative Review

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.

Military Veteran Status and Posttraumatic Stress Disorder Symptomatology Among Urban Firefighters: The Moderating Role of Emotion Regulation Difficulties

A significant portion of firefighters are military veterans, and both populations experience high rates of trauma and posttraumatic stress disorder (PTSD) symptomatology. We investigated main and interactive effects of military veteran status (MVS) and emotion regulation difficulties (ERD) with regard to PTSD symptom severity in firefighters. Covariates included trauma load, number of years in the fire department, and depressive symptom severity. The sample was composed of 839 (93.9% men; mean age = 38.4, SD = 8.5) trauma-exposed firefighters who completed a web-based questionnaire battery. Structural equation modeling was used. ERD were significantly, positively associated with PTSD symptom severity (β = 0.30, confidence interval [CI] = 0.20-0.41, p < 0.001). A significant interactive effect was noted (β = 0.07, CI = 0.01-0.14, p = 0.020); firefighters who endorsed MVS and greater ERD had the highest levels of PTSD symptom severity. It is vital that future work examine associations between MVS and relevant cognitive mechanisms for the purposes of informing effective screening, intervention, and prevention programs.

Understanding mental health among military veterans in the fire service

Firefighters who have previously served in the military may be at potentially higher risk for worsened mental health outcomes. This investigation examined the mental health of military veterans, as compared to non-veterans, in the fire service. We hypothesized that firefighters who endorsed military veteran status would have higher rates of mental health symptoms, in comparison to firefighters who did not endorse prior service in the military. Age, gender, and race/ethnicity were used as covariates. The sample was comprised of 910 career firefighters, 209 (23.0%) of whom endorsed military veteran status. One-way analyses of covariance were employed. The military veteran subsample reported significantly higher levels of sleep disturbance, depression, and posttraumatic stress symptom severity in comparison to the non-veteran subsample; however, effect sizes were small indicating that between group differences are actually negligible. Results highlight the need to improve our understanding of risk and resilience factors for firefighters who have served in the military, as this line of inquiry has potentially important mental health intervention implications for this exceptionally understudied population.

Sources of moral injury among war veterans: A qualitative evaluation

OBJECTIVE

Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events.

METHOD

Six focus groups with US war veterans were conducted.

RESULTS

Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veteran's reported distress is related to his own behavior) versus Responsibility of Others (veteran's distress is related to actions taken by others). Examples of each type of morally injurious event are provided.

CONCLUSIONS

Implications for the further development of the moral injury construct and treatment are discussed.

Influence of military sexual assault and other military stressors on substance use disorder and PTS symptomology in female military veterans

Servicewomen exposed to traumatic stressors over the course of their military service are at increased risk of developing symptoms of substance use disorder (SUD) and posttraumatic stress (PTS). They are also at risk for exposure to military sexual assault (MSA), which is also associated with SUD and PTS symptomology. Research is unclear about the incremental contributions of different forms of traumatic stressors on co-occurring SUD and PTS symptomology. In this study we examined the independent and combined effects of MSA and other military stressors on SUD and PTS symptomology in a sample of female veterans (N=407). Results indicate that MSA and other military stressors exhibit incremental effects on SUD and PTS symptomology. Results further suggest that women exposed to both MSA and other military stressors are at increased risk for developing co-occurring SUD and PTSD. These findings extend previous research on comorbid SUD and PTSD, highlighting the cumulative effects of traumatic stressors on posttraumatic psychopathology, and have implications for future research and clinical practice with female veterans.

Alcohol Misuse in Reserve Soldiers and their Partners: Cross-Spouse Effects of Deployment and Combat Exposure

BACKGROUND

Military deployment and combat are associated with worse outcomes, including alcohol misuse. Less is known about how these experiences affect soldiers' spouses.

OBJECTIVE

The study objective was to explore relationships between deployment, combat exposure, and alcohol misuse; especially cross-spouse effects (effect of one partner's experiences/behavior on the other partner), which has been under-examined in military samples.

METHODS

U.S. Army Reserve/National Guard soldiers and their partners completed a questionnaire covering physical and mental health, military service and substance use. Negative binomial regression models examined number of deployments and combat exposure individually for alcohol misuse and frequent heavy drinking (FHD). In additional models, we examined combat exposure's role on alcohol outcomes, controlling for the soldiers' number of deployments, PTSD symptoms, age, and in cross-spouse models, alcohol use and FHD. We considered individuals' deployment experiences related to their alcohol outcomes and to their spouses' alcohol outcomes.

RESULTS

The study sample included male soldiers with current/lifetime military service (n = 248) and their female partners. Combat exposure was related to FHD (RR: 1.01, p < .05, 95% CI: 1.01, 1.01) among male soldiers while controlling for PTSD symptoms, number of deployments, and age. Female partners of male soldiers were more likely to engage in FHD (RR: 1.01, p < .05, 95% CI: 1.01, 1.01) if their spouse experienced combat.

CONCLUSIONS

Our results demonstrate that male soldiers and their spouses are at increased risk of FHD if the soldier experienced combat. This points to the need for better screening, particularly of spouses of soldiers, whose alcohol misuse may be overlooked.

Moral injury process and its psychological consequences among Israeli combat veterans

OBJECTIVES

We aim to examine the link between exposure to potentially morally injurious events (PMIEs) and posttraumatic stress disorder symptoms (PTSS). We also aim to explore the mediating roles of depressive attributions, trauma-related guilt and shame, and self-disgust in the relationship between PMIEs and PTSS among combat veterans.

METHOD

A volunteers' sample of 191 Israeli combat veterans responded to self-report questionnaires in a cross-sectional design study.

RESULTS

More than one-fifth of the sample reported experiencing PMIEs but only betrayal based experience was related to PTSS. Importantly, betrayal based experience was associated with depressive attributions which increased the level of trauma-related distressing guilt, intrinsic shame and self-disgust, which in turn were associated with high levels of PTSS.

CONCLUSIONS

PMIEs, and especially betrayal based experiences, are related to PTSS among Israeli veterans. Depressive attributions, trauma-related distressing guilt, intrinsic shame, and self-disgust might serve as possible mechanisms for the links between PMIEs and PTSS.

The Influence of Social Support on Dyadic Functioning and Mental Health Among Military Personnel During Postdeployment Reintegration

OBJECTIVES

Although many service members successfully cope with exposure to stress and traumatic experiences, others have symptoms of depression, posttraumatic stress disorder (PTSD), and anxiety; contextual factors may account for the variability in outcomes from these experiences. This work sought to understand mechanisms through which social support influences the mental health of service members and whether dyadic functioning mediates this relationship.

METHODS

We collected cross-sectional data as part of a larger study conducted in 2013; 321 military personnel who had at least 1 deployment were included in these analyses. Surveys were completed online; we collected data on demographic characteristics, social support, mental health measures (depression, PTSD, and anxiety), and dyadic functioning. We performed process modeling through mediation analysis.

RESULTS

The direct effects of social support on the mental health of military personnel were limited; however, across all types of support networks, greater social support was significantly associated with better dyadic functioning. Dyadic functioning mediated the relationships between social support and depression/PTSD only when social support came from nonmilitary friends or family; dyadic functioning mediated social support and anxiety only when support came from family. We found no indirect effects of support from military peers or military leaders.

CONCLUSION

Findings here highlight the need to continue to explore ways in which social support, particularly from family and nonmilitary-connected peers, can bolster healthy intimate partner relationships and, in turn, improve the well-being of military service members who are deployed.

Examining weight and eating behavior by sexual orientation in a sample of male veterans

OBJECTIVE

Eating disorders are understudied in men and in sexual minority populations; however, extant evidence suggests that gay men have higher rates of disordered eating than heterosexual men. The present study examined the associations between sexual orientation, body mass index (BMI), disordered eating behaviors, and food addiction in a sample of male veterans.

METHOD

Participants included 642 male veterans from the Knowledge Networks-GfK Research Panel. They were randomly selected from a larger study based on previously reported trauma exposure; 96% identified as heterosexual. Measures included the Eating Disorder Diagnostic Scale, the Yale Food Addiction Scale, and self-reported height and weight.

RESULTS

Heterosexual and sexual minority men did not differ significantly in terms of BMI. However, gay and bisexual men (n=24) endorsed significantly greater eating disorder symptoms and food addiction compared to heterosexual men.

CONCLUSIONS

Our findings that sexual minority male veterans may be more likely to experience eating disorder and food addiction symptoms compared to heterosexual male veterans highlight the importance of prevention, assessment, and treatment efforts targeted to this population.

Drinking to ease the burden: a cross-sectional study on trauma, alcohol abuse and psychopathology in a post-conflict context

BACKGROUND

It is likely that alcohol use and abuse increase during and after violent conflicts. The most prominent explanation of this phenomenon has been referred to as self-medication hypothesis. It predicts that psychotropic substances are consumed to deal with conflict-related psychic strains and trauma. In northern Uganda, a region that has been affected by a devastating civil war and is characterized by high levels of alcohol abuse we examined the associations between war-trauma, childhood maltreatment and problems related to alcohol use. Deducing from the self-medication hypothesis we assumed alcohol consumption moderates the relationship between trauma-exposure and psychopathology.

METHODS

A cross-sectional epidemiological survey targeting war-affected families in post-conflict northern Uganda included data of male (n = 304) and female (n = 365) guardians. We used standardized questionnaires in an interview format to collect data on the guardians' socio-demography, trauma-exposure, alcohol consumption and symptoms of alcohol abuse, PTSD and depression.

RESULTS

Symptoms of current alcohol use disorders were present in 46 % of the male and 1 % of the female respondents. A multiple regression model revealed the unique contributions of emotional abuse in the families of origin and trauma experienced outside the family-context in the prediction of men's alcohol-related symptoms. We found that alcohol consumption moderated the dose-effect relationship between trauma-exposure and symptoms of depression and PTSD. Significant interactions indicated that men who reported more alcohol-related problems experienced less increase in symptoms of PTSD and depression with increasing trauma-exposure.

CONCLUSIONS

The gradual attenuation of the dose-effect the more alcohol-related problems were reported is consistent with the self-medication hypothesis. Hence, the functionality of alcohol consumption has to be considered when designing and implementing addiction treatment in post-conflict contexts.

Cross (Unit)-Level Effects of Cohesion on Relationships of Suicide Thoughts to Combat Exposure, Postdeployment Stressors, and Postdeployment Social Support

A behavioral health concern for the US military has been suicide, largely due to its increased prevalence in the last several years during US involvement in the Iraq and Afghanistan wars. Using hierarchical linear modeling (HLM), the present study examined relationships among combat exposure, postdeployment stressors, social support, and unit cohesion. Survey data were obtained from 4,567 soldiers who were members of 50 company-sized units. At the individual level, combat exposure and postdeployment stressors were associated with suicidal thoughts. Postdeployment social support was associated with fewer suicidal thoughts. There was no evidence of the stress-buffering effect of social support. At the group level, reduced risk for suicidal thoughts was associated with units having higher than average cohesion. Reduced risk for suicidal thoughts in conjunction with combat experiences was observed in units having higher than average cohesion, though not reaching a traditional level of statistical significance.

Eating disorders in military and veteran men and women: A systematic review

OBJECTIVE

Eating disorders (EDs) have serious consequences for psychological and physical health. They have high mortality rates and are among the most costly disorders to treat. However, EDs remain understudied in military and veteran populations. The aim of this review was to examine prevalence estimates and associated symptomatology of EDs among military and veteran men and women and to identify factors that may put these individuals at risk for the development of an ED for the purposes of improving detection, intervention, and treatment.

METHOD

A thorough literature review was conducted using the databases PsycINFO and PubMed. All articles with a focus on EDs in military/veteran samples were considered.

RESULTS

Studies reveal high prevalence estimates of EDs among military/veteran men and women. Unique features of military life may increase the risk for development of an ED, including: military sexual trauma, strict weight and physical fitness requirements, and combat exposure. A history of trauma was common in individuals diagnosed with an ED in military and veteran samples.

DISCUSSION

The high rates of EDs among military and veteran samples underscore the importance of further research, as well as the importance of screening and intervention efforts, in these understudied populations.

Combat high or traumatic stress: violent offending is associated with appetitive aggression but not with symptoms of traumatic stress

Former members of armed groups in eastern DR Congo had typically witnessed, experienced, and perpetrated extreme forms of violence. Enhanced trauma-related symptoms had been shown in prior research. But also lashing out in self-defense is a familiar response to threat defined as reactive aggression. Another potential response is appetitive aggression, in which the perpetration of excessive violence is perceived as pleasurable (combat high). What roles do these forms of aggressive behavior play in modern warfare and how are they related to posttraumatic stress symptoms? To answer the question, we sought to determine predictors for appetitive aggressive and trauma-related mental illness, and investigated the frequency of psychopathological symptoms for high- and low-intensity conflict demobilization settings. To this end, we interviewed 213 former members of (para)military groups in the eastern Democratic Republic of Congo in regard to their combat exposure, posttraumatic stress, appetitive aggression, depression, suicidality, and drug dependence. Random forest regression embedded in a conditional inference framework revealed that perpetrated violent acts are not necessarily stressful. In fact, the experience of violent acts that typically implicated salient cues of hunting (e.g., blood, suffering of the victim, etc.) had the strongest association with an appetite for aggression. Furthermore, the number of lifetime perpetrated violent acts was the most important predictor of appetitive aggression. However, the number of perpetrated violent acts did not significantly affect the posttraumatic stress. Greater intensity of conflict was associated with more severe posttraumatic stress symptoms and depression. Psychotherapeutic interventions that address appetitive aggression in addition to trauma-related mental illness, including drug dependence, therefore seem indispensible for a successful reintegration of those who fought in the current civil wars.

Posttraumatic stress disorder according to DSM-5 and DSM-IV diagnostic criteria: a comparison in a sample of Congolese ex-combatants

BACKGROUND

Compared to DSM-IV, the criteria for diagnosing posttraumatic stress disorder (PTSD) have been modified in DSM-5.

OBJECTIVE

The first aim of this study was to examine how these modifications impact rates of PTSD in a sample of Congolese ex-combatants. The second goal of this study was to investigate whether PTSD symptoms were associated with perpetrator-related acts or victim-related traumatic events.

METHOD

Ninety-five male ex-combatants in the eastern Democratic Republic of Congo were interviewed. Both the DSM-IV and the DSM-5 PTSD symptom criteria were assessed.

RESULTS

The DSM-5 symptom criteria yielded a PTSD rate of 50% (n=47), whereas the DSM-IV symptom criteria were met by 44% (n=42). If the DSM-5 would be set as the current "gold standard," then DSM-IV would have produced more false negatives (8%) than false positives (3%). A minority of participants (19%, n=18) indicated an event during which they were involved as a perpetrator as their most stressful event. RESULTS of a regression analysis (R (2)=0.40) showed that, after accounting for the number of types of traumatic events, perpetrated violent acts were not associated with the symptom severity of PTSD.

CONCLUSIONS

The findings demonstrate that more diagnostic cases were produced with the DSM-5 diagnostic rules than were dropped resulting in an increase in PTSD rates compared to the DSM-IV system. The missing association between PTSD symptoms and perpetrated violent acts might be explained by a potential fascinating and excited perception of these acts.

Moral engagement, combat trauma, and the lure of psychiatric dualism: why psychiatry is more than a technical discipline

Psychiatry is not only a technical discipline concerned with matching appropriate means to pre-specified ends; it is also a discipline of moral engagement and discernment in which clinicians and patients explore the ends that patients will pursue. Moral engagement is intrinsic to psychiatric practice, particularly when psychiatrists engage issues such as combat trauma in which patients' moral self-evaluations are relevant to the perpetuation of psychological distress. Relative to technical models of practice, however, the space of moral engagement and discernment conveys risk for psychiatrists as it is less "scientific," more prone to exploitation and abuse, and the occasion for social-political critiques of psychiatry. Three prevalent forms of psychiatric dualism, each manifest in the care of combat veterans, seem to allow psychiatrists to avoid this contested moral space: dualism of the self and the self's body, dualism of the self and the self's quantifiable experience and behavior, and dualism of the self and the self's "values." Each of these dualisms is alluring but ultimately unable to protect psychiatrists from the space of moral engagement. Psychiatrists must rather cultivate practices for inhabiting that space in a morally transparent, self-questioning, and responsible way.

Development of exposure to combat severity scale of the combat experiences questionnaire (CEQ)

Combat exposure is detrimental to physical and mental health, and is an important risk factor for Post-traumatic Stress Disorder (PTSD). The current study aimed to develop the first section of a self-report measure (Combat Experiences Questionnaire - CEQ), and to explore its psychometric properties on Portuguese Overseas War Veterans. The Exposure to Combat Severity Scale (CEQ A), assesses the exposure severity to objective scenarios related to military combat, common to contemporary and older theaters of operations. Studies included structural analysis through Rash Model, internal consistency, convergent validity (n=708), temporal reliability (n=112) and sensibility to differentiate war Veterans with and without war-related PTSD (N=40 and N=47, respectively). The scale's structure presented adequate fit to the data, adequate psychometric properties, and discriminant validity. Thus, the CEQ A is a valid and reliable tool presenting diverse combat scenarios to assess severity of combat exposure in war Veterans.

A qualitative analysis of the experience and impact of killing in hand-to-hand combat

A growing body of research suggests that killing during military combat is closely associated with posttraumatic stress disorder (PTSD), as well as a number of other adverse mental health related conditions (e.g., dissociative experiences, violent behavior, functional impairment). This article provides first-person perspectives on the experiences and impact of killing by service members with the goal of expanding our understanding of the impact of taking a life during war. In audio-recorded phenomenological interviews, 9 service members described their experiences and the subsequent impact of killing during hand-to-hand combat. A description, supported by participant quotations, was constructed to represent the participants' experiences. Results suggest the experience and aftermath of taking a life in hand-to-hand combat was disturbing, psychologically stressful, and necessitated some form of coping after the event. Service members who killed in hand-to-hand combat viewed their actions as necessary to preserve their life and that killing in hand-to-hand combat was more emotionally taxing than killing by shooting. Our findings may help to improve providers' understanding of service members' first-person experiences of killing in hand-to-hand combat and thus provide the basis for the development of a connected and genuine relationship with such military clients.

Changes in alcohol use after traumatic experiences: the impact of combat on Army National Guardsmen

OBJECTIVE

This research documents the impact of combat experiences on alcohol use and misuse among National Guard soldiers. Whereas much research regarding combat personnel is based on post-experience data, this study's design uses both pre- and post-deployment data to identify the association between different types of combat experiences and changes in substance use and misuse.

METHOD

A National Guard Infantry Brigade Combat Team was surveyed before and after its deployment to Iraq in 2005-2006. Members of the unit completed anonymous surveys regarding behavioral health and alcohol use and, in the post-survey, the combat experiences they had during deployment. The unit was surveyed 3 months prior to its deployment and 3 months after its deployment.

RESULTS

Prevalence rates of alcohol use increased from 70.8% pre-deployment to 80.5% post-deployment. Prevalence rates of alcohol misuse more than doubled, increasing from 8.51% before deployment to 19.15% after deployment. However, among the combat experiences examined in this study, changes in alcohol misuse post-deployment appear to be solely affected by the combat experience of killing. Alcohol misuse decreased amongst those who experienced killing during combat.

CONCLUSIONS

This study highlights the role of combat experiences on substance use.

Trauma-related correlates of alcohol use in recently deployed OEF/OIF veterans

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma-related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in-person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co-occurring PTSD and AUD among veterans postdeployment.

Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans

BACKGROUND

Our goal was to better understand distinct PTSD symptom presentations in Iraq and Afghanistan Veterans (N=227) and to determine whether those who killed in war were at risk for being in the most symptomatic class.

METHODS

We used latent class analysis of responses to the PTSD checklist and logistic regression of most symptomatic class.

RESULTS

We found that a four-class solution best fit the data, with the following profiles emerging: High Symptom (34% of participants), Intermediate Symptom (41%), Intermediate Symptom with Low Emotional Numbing (10%), and Low Symptom (15%). The largest group of individuals who reported killing (45%) was in the High Symptom class, and those who killed had twice the odds of being in the most symptomatic PTSD class, compared to those who did not kill. Those who endorsed killing a non-combatant (OR=4.56, 95% CI [1.77, 11.7], p<0.01) or killing in the context of anger or revenge (OR=4.63, 95% CI=[1.89, 11.4], p<0.001) were more likely to belong to the most symptomatic PTSD class, compared to those who did not kill.

LIMITATIONS

The study was retrospective and cross-sectional. The results may not generalize to veterans of other wars.

CONCLUSIONS

Killing in war may be an important indicator of risk for developing frequent and severe PTSD symptoms. This has implications for the mental healthcare of veterans, providing evidence that a comprehensive evaluation of returning veterans should include an assessment of killing experiences and reactions to killing.

Using a Bug-Killing Paradigm to Understand How Social Validation and Invalidation Affect the Distress of Killing

Clinical evidence demonstrates that killing among soldiers at war predicts their experience of long-lasting trauma/distress. Killing leads to distress, in part, due to guilt experienced from violating moral standards. Because social consensus shapes what actions are perceived as moral and just, we hypothesized that social validation for killing would reduce guilt, whereas social invalidation would exacerbate it. To examine this possibility in a laboratory setting, participants were led to kill bugs in an “extermination task.” Perceptions of social validation/invalidation were manipulated through the supposed actions of a confederate (Study 1) or numerous previous participants (Study 2) that agreed or refused to kill bugs. Distress measures focused on trauma-related guilt. Higher levels of distress were observed when individuals perceived their actions as invalidated as opposed to when they perceived their actions as socially validated. Implications for posttraumatic stress disorder (PTSD) experienced by soldiers and the paradoxical nature of publicly expressing antiwar sentiments are discussed.

Killing in combat may be independently associated with suicidal ideation

BACKGROUND

The United States military has lost more troops to suicide than to combat for the second year in a row and better understanding combat-related risk factors for suicide is critical. We examined the association of killing and suicide among war veterans after accounting for PTSD, depression, and substance use disorders.

METHODS

We utilized a cross-sectional, retrospective, nationally representative sample of Vietnam veterans from the National Vietnam Veterans Readjustment Study (NVVRS). In order to perform a more in depth analysis, we utilized a subsample of these data, the NVVRS Clinical Interview Sample (CIS), which is representative of 1.3 million veterans who were eligible for the clinical interview by virtue of living in proximity to an interview site, located within 28 standard metropolitan regions throughout the United States.

RESULTS

Veterans who had higher killing experiences had twice the odds of suicidal ideation, compared to those with lower or no killing experiences (OR = 1.99, 95% CI = 1.07-3.67), even after adjusting for demographic variables, PTSD, depression, substance use disorders, and adjusted combat exposure. PTSD (OR = 3.42, 95% CI = 1.09-10.73), depression (OR = 11.49, 95% CI = 2.12-62.38), and substance use disorders (OR = 3.98, 95% CI = 1.01-15.60) were each associated with higher odds of suicidal ideation. Endorsement of suicide attempts was most strongly associated with PTSD (OR = 5.52, 95% CI = 1.21-25.29).

CONCLUSIONS

Killing experiences are not routinely examined when assessing suicide risk. Our findings have important implications for conducting suicide risk assessments in veterans of war. Depression and Anxiety 00:1-6, 2012. © 2012 Wiley Periodicals, Inc.