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Kok BC, Dux M, Lee-Wilk T, Clarke-Walper K, Wilk JE. Differential impact of type of killing on posttraumatic stress disorder symptoms in U.S. Army soldiers deployed to Afghanistan. J Trauma Stress 2023; 36:1151-1156. [PMID: 37705140 DOI: 10.1002/jts.22971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 09/15/2023]
Abstract
Over the past 20 years, U.S. military conflicts in Iraq and Afghanistan have been marked by high rates of combat and wartime killings. Research on Vietnam-era service members suggests that the type of killing (i.e., killing a combatant vs. noncombatant) is an important predictor of later mental health problems, including posttraumatic stress disorder (PTSD). The present study aimed to update these findings by exploring the impact of type of killing on PTSD symptoms using a sample of postdeployment active duty U.S. Army personnel (N = 875). Using multiple regression analysis, we found that the act of killing a noncombatant was significantly associated with PTSD symptoms, B = 7.50, p < .001, whereas killing a combatant was not, B = -0.85, p = .360. This remained significant after controlling for demographic variables, depressive symptoms, and general combat experiences. These findings support the need for thoughtful postdeployment screenings and targeted clinical interventions.
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Affiliation(s)
- Brian C Kok
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Moira Dux
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Terry Lee-Wilk
- VA Maryland Health Care System, Baltimore, Maryland, USA
| | - Kristina Clarke-Walper
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Joshua E Wilk
- Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Kidwell MC, Kerig PK. To Trust is to Survive: Toward a Developmental Model of Moral Injury. J Child Adolesc Trauma 2023; 16:459-475. [PMID: 37234829 PMCID: PMC10205960 DOI: 10.1007/s40653-021-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Mallory C. Kidwell
- Department of Psychology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112 USA
| | - Patricia K. Kerig
- Department of Psychology, University of Utah, 380 S 1530 E, Salt Lake City, UT 84112 USA
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Dumke L, Haer R, Zawadka A, Salmen C, Hecker T. The role of violence perpetration in driving externalizing problems and offending behavior among youth from eastern Democratic Republic of Congo. J Trauma Stress 2022; 35:1696-1708. [PMID: 36047455 DOI: 10.1002/jts.22871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 12/24/2022]
Abstract
Youth in conflict-affected regions are exposed to a multitude of traumatic events. These individuals often witness violence; experience it firsthand; and, in some cases, become perpetrators. The interplay of events shapes systematic trauma histories that may have unique implications for youths' mental health. In a cross-sectional study conducted in eastern Democratic Republic of Congo (DRC), we interviewed 295 war-affected youth (63.4% boys, Mage = 16.70 years), including former child soldiers (n = 171), regarding their traumatic experiences and mental health. Using latent class analysis, we identified four common trauma history classes categorized by (a) low exposure, (b) medium exposure, (c) high exposure, and (d) high exposure/perpetration. Across the sample, gradual increases in trauma load corresponded with increased vulnerability to posttraumatic stress disorder (PTSD) symptoms, ηp 2 = .36, and internalizing problems, ηp 2 = .12; however, only youth from the high exposure/perpetration class differed significantly from other youth in their levels of externalizing problems, ηp 2 = .13, and offending behaviors, ηp 2 = .17. A longer time in armed groups was related to a higher risk of both experiencing and perpetrating violence. The results indicate that it is not child soldier status, per se, but the perpetration of violence that reinforces a cycle of violence in conflict-affected societies by contributing to increased externalizing problems and offending behaviors. In conflict regions, integrated approaches are needed to address both trauma and externalizing problems of war-affected youth.
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Affiliation(s)
- Lars Dumke
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Roos Haer
- Institute of Political Science, University of Leiden, Leiden, Netherlands
| | - Annika Zawadka
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | | | - Tobias Hecker
- Department of Psychology, Bielefeld University, Bielefeld, Germany
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Kelley ML, Strowger M, Chentsova VO, Bravo AJ, Gaylord SA, Burgin EE, Vinci C, Ayers KL, Agha E. Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury. Contemp Clin Trials Commun 2022; 30:101011. [PMID: 36340697 PMCID: PMC9626875 DOI: 10.1016/j.conctc.2022.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 10/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code. Objective We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program. Methods Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms. Results Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022. Conclusion MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.
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Affiliation(s)
- Michelle L. Kelley
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Corresponding author. Department of Psychology, Old Dominion University, 250 Mills Godwin Building, Norfolk, VA, 23529, USA.
| | - Megan Strowger
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
| | | | - Adrian J. Bravo
- Department of Psychological Sciences, William & Mary, Williamsburg, VA, USA
| | - Susan A. Gaylord
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth E. Burgin
- School Psychology and Counselor Education, William & Mary, Williamsburg, VA, USA
| | - Christine Vinci
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth L. Ayers
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | - Erum Agha
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Senecal G, Adorno RL, LaFleur R, McNamara KA. Autoethnographic Family Case Study: Combat Veteran PTSD and its Effects on Familial Dynamics, Parenting, and Marriage. Journal of Veterans Studies 2022. [DOI: 10.21061/jvs.v8i3.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Maguen S, Griffin BJ, Copeland LA, Perkins DF, Richardson CB, Finley EP, Vogt D. Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression. Psychol Med 2022; 52:2332-2341. [PMID: 33234177 PMCID: PMC9527674 DOI: 10.1017/s0033291720004249] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon J. Griffin
- Central Arkansas VA Healthcare System, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Laurel A. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | - Erin P. Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Dawne Vogt
- National Center for PTSD at VA Boston Health Care System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Jin J, Weiman K, Bremault-Phillips S, Vermetten E. Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts. Front Psychiatry 2022; 13:880442. [PMID: 35774092 PMCID: PMC9237246 DOI: 10.3389/fpsyt.2022.880442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery. Objectives In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI. Materials and Methods Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology. Results Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity. Conclusion Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.
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Affiliation(s)
- Jonathan Jin
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Kyle Weiman
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Suzette Bremault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
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Abstract
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.
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Affiliation(s)
- Kristine Burkman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
| | - Rebecca Gloria
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Haley Mehlman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Shira Maguen
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
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Cypel Y, Schnurr PP, Schneiderman AI, Culpepper WJ, Akhtar FZ, Morley SW, Fried DA, Ishii EK, Davey VJ. The mental health of Vietnam theater veterans-the lasting effects of the war: 2016-2017 Vietnam Era Health Retrospective Observational Study. J Trauma Stress 2022; 35:605-618. [PMID: 35290689 PMCID: PMC9310606 DOI: 10.1002/jts.22775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
Mental health data from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) were analyzed by cohort, represented by United States Vietnam theater veterans (VTs) who served in Vietnam, Cambodia, and Laos; nontheater veterans (NTs) without theater service; and age- and sex-matched nonveterans (NVs) without military service. The exposure of interest was Vietnam theater service. Surveys mailed to random samples of veterans (n = 42,393) and nonveterans (n = 6,885) resulted in response rates of 45.0% for veterans (n = 6,735 VTs, Mage = 70.09, SE = 0.04; n = 12,131 NTs) and 67.0% for NVs (n = 4,530). We examined self-report data on four mental health outcomes: probable posttraumatic stress disorder (PTSD), depression, psychological distress, and overall mental health functioning. Weighted adjusted odds ratios (aORs) between each outcome and cohort were estimated, controlling for covariates in four models: cohort plus sociodemographic variables (Model 1), Model 1 plus physical health variables (Model 2), Model 2 plus potentially traumatic events (PTEs; Model 3), and Model 3 plus other military service variables (Model 4). Mental health outcome prevalence was highest for VTs versus other cohorts, with the largest aOR, 2.88, for PTSD, 95% CI [2.46, 3.37], p < .001 (Model 4, VT:NT). Physical health and PTEs contributed most to observed effects; other service variables contributed least to aORs overall. Mental health dysfunction persists among VTs years after the war's end. The present results reaffirm previous findings and highlight the need for continued mental health surveillance in VTs.
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Affiliation(s)
- Yasmin Cypel
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Paula P. Schnurr
- National Center for PTSDU.S. Department of Veterans AffairsWhite River JunctionVermontUSA,Department of PsychiatryGeisel School of Medicine at DartmouthHanoverNew HampshireUSA
| | - Aaron I. Schneiderman
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - William J. Culpepper
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Fatema Z. Akhtar
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Sybil W. Morley
- VISN 2 Center of Excellence for Suicide PreventionU.S. Department of Veterans AffairsCanandaiguaNew YorkUSA
| | - Dennis A. Fried
- War Related Injury & Illness Study CenterU.S. Department of Veterans AffairsEast OrangeNew JerseyUSA
| | - Erick K. Ishii
- Population Health Services (10P4V)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Victoria J. Davey
- Office of Research & Development (14RD)U.S. Department of Veterans AffairsWashingtonD.C.USA
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Hertz U, Snider KLG, Levy A, Canetti D, Gross ML. To shoot or not to shoot: experiments on moral injury in the context of West Bank checkpoints and COVID-19 restrictions enforcement. Eur J Psychotraumatol 2022; 13:2013651. [PMID: 35087644 PMCID: PMC8788350 DOI: 10.1080/20008198.2021.2013651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Does exposure to events that transgress accepted norms, such as killing innocent civilians, prompt the psychological and emotional consequences of moral injury among soldiers? Moral injury is associated with negative emotions such as guilt, shame and anger, and a sense of betrayal and is identified among veterans following exposure to potentially morally injurious events (PMIE). OBJECTIVE We experimentally investigate how PMIE characteristics affect the intensity of MI and related negative moral emotions in participants with varied military experience. METHOD We conducted three controlled, randomized experiments. Each exposed male respondents with active combat experience (Study 1) and varied military experience (Study 2) to four textual vignettes describing PMIE (child/adult and innocent/non-innocent suspect) that transpire at an Israeli checkpoint in the West Bank. In study 3, we exposed participants to two scenarios, where descriptions of police officers enforcing COVID 19 restrictions confronted lockdown violators. RESULTS Participants assigned to vignettes describing killing an innocent civilian exhibited more intense levels of shame and guilt than those assigned to vignettes describing killing a person carrying a bomb. Religiosity and political ideology were strong predictors of guilt and shame in response to descriptions of checkpoint shootings. These effects disappeared in Study 3, suggesting that political ideology drives MI in intergroup conflict. CONCLUSIONS Background and PMIE-related characteristics affect the development of moral injury. Additionally, lab experiments demonstrate the potential and limitations of controlled studies of moral injury and facilitate an understanding of the aetiology of moral injury in a way unavailable to clinicians. Finally, experimental findings and methodologies offer further insights into the genesis of moral injury and avenues for therapy and prophylaxis.
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Affiliation(s)
- Uri Hertz
- Department of Cognitive Sciences, University of Haifa, Haifa, Israel
| | | | - Adi Levy
- School of Political Science, University of Haifa, Haifa, Israel
| | - Daphna Canetti
- School of Political Science, University of Haifa, Haifa, Israel
| | - Michael L Gross
- School of Political Science, University of Haifa, Haifa, Israel
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Khan AJ, Campbell-Sills L, Sun X, Kessler RC, Adler AB, Jain S, Ursano RJ, Stein MB. Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers. JAMA Netw Open 2021; 4:e2130810. [PMID: 34724553 PMCID: PMC8561325 DOI: 10.1001/jamanetworkopen.2021.30810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Amanda J. Khan
- Department of Psychiatry, University of California San Diego, La Jolla
| | | | - Xiaoying Sun
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Amy B. Adler
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Sonia Jain
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
- Psychiatry Service, Veterans Affairs San Diego Healthcare System, San Diego, California
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Okulate GT, Akinsanmi MA, Oguntuase RA, Majebi MA. Moral Injury Among Nigerian Soldiers Following Combat: Case Reports and a Review of the Literature. Mil Med 2021; 186:e1048-e1052. [PMID: 33242066 DOI: 10.1093/milmed/usaa373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/03/2020] [Accepted: 09/15/2020] [Indexed: 11/13/2022] Open
Abstract
Moral injury is a phenomenon in which unpleasant psychological consequences such as guilt and shame follow exposure to activities that transgress one's deeply held moral beliefs and expectations. Combat engagement places service members at a heightened risk on account of exposure to potentially morally injurious experiences (PMIEs). It remains a more recent construct in comparison with posttraumatic stress disorder (PTSD) despite several studies. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) effectively subsumed moral injury as a part of PTSD, recognizing moral injury as symptoms rather than events that are followed by specific symptoms. Nothing has been reported on moral injury, its prevalence, and associated factors among Nigerian soldiers despite exposure to PMIE in combat and abundance of literature worldwide. Unlike PTSD, moral injury is often under-recognized by clinicians and military and nonmilitary health personnel, and particularly, in our setting where nonmilitary mental health personnel sometimes have to treat postcombat military patients. Failure of recognition of moral injury (and not addressing it) can adversely affect overall mental health and may increase the risk of suicide. We report three cases of personnel of the Nigerian Army referred to our clinic after combat in northeastern Nigeria and following exposure to PMIE, the circumstances of exposure to morally injurious situations and subsequent reactions. Our study brought up several findings including the effect of exposure to multiple potentially injurious events, apparent frequent co-occurrence of moral injury with PTSD, and the complicating unpleasant mental health outcomes. Being a report of cases, this implies that generalizations might not be warranted but serve as possible questions for future research.
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Affiliation(s)
- Gbenga Taiwo Okulate
- Department of Psychiatry, 68 Nigerian Army Reference Hospital Myhoung Barracks Yaba, Lagos, PMB 2004, Nigeria
| | - Mojisola Abosede Akinsanmi
- Department of Psychiatry, 68 Nigerian Army Reference Hospital Myhoung Barracks Yaba, Lagos, PMB 2004, Nigeria
| | - Rufus Akinwande Oguntuase
- Department of Psychiatry, 68 Nigerian Army Reference Hospital Myhoung Barracks Yaba, Lagos, PMB 2004, Nigeria
| | - Michael Adeiza Majebi
- Department of Psychiatry, 68 Nigerian Army Reference Hospital Myhoung Barracks Yaba, Lagos, PMB 2004, Nigeria
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Frankfurt SB, Coady A. Judgments of Morality in War: Commentary on Watkins (2020). Perspect Psychol Sci 2021; 16:1456-1460. [PMID: 34436939 DOI: 10.1177/1745691621991881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sheila B Frankfurt
- Veterans Integrated Service Network (VISN) 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas.,Central Texas Veterans Healthcare System, Temple, Texas
| | - Alanna Coady
- Department of Psychology, University of British Columbia-Okanagan
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14
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Houle SA, Vincent C, Jetly R, Ashbaugh AR. Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: A multi-method analysis. J Clin Psychol 2021; 77:2668-2693. [PMID: 34224575 DOI: 10.1002/jclp.23205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/27/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study describes patterns of distress associated with exposure to potentially morally injurious experiences (PMIEs) in a Canadian military sample. METHOD Thematic analysis was performed on interviews from PMIE-exposed military members and Veterans. Participants also completed structured diagnostic interviews, and measures of trauma exposure and psychopathology. Multiple regression examined associations among these variables. Information on pharmacological treatment and past diagnoses are reported. RESULTS Eight qualitative themes were identified: changes in moral attitudes, increased sensitivity and reactivity to moral situations, loss of trust, disruptions in identity, disruptions in spirituality, disruptions in interpersonal relatedness, rumination, and internalizing and externalizing emotions and behaviors. Self-report data revealed that degree of PMIE exposure was meaningfully associated with posttraumatic stress disorder. CONCLUSION Qualitative but not quantitative findings supported existing models of moral injury (MI). Additional research is needed to examine the impact of PMIE type on mental health, and to test basic assumptions of MI theory.
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Affiliation(s)
| | - Colin Vincent
- Operational Stress Injury Clinic, Royal Ottawa Health Care Group, Ottawa, Canada
| | - Rakesh Jetly
- The Royal's Institute of Mental Health Research, Ottawa, Canada
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15
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Michaud K, Suurd Ralph C, Connick-Keefer SJA. Operational stressors, psychological distress, and turnover intentions: The impact of potentially morally injurious experiences. Military Psychology 2021. [DOI: 10.1080/08995605.2021.1906075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kathy Michaud
- Department of National Defence, Ottawa, Ontario, Canada
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17
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Legate N, Weinstein N, Ryan RM. Ostracism in Real Life: Evidence That Ostracizing Others Has Costs, Even When It Feels Justified. Basic and Applied Social Psychology 2021. [DOI: 10.1080/01973533.2021.1927038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Zefferman MR, Mathew S. Combat stress in a small-scale society suggests divergent evolutionary roots for posttraumatic stress disorder symptoms. Proc Natl Acad Sci U S A 2021; 118:e2020430118. [PMID: 33876754 DOI: 10.1073/pnas.2020430118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Did PTSD and combat stress evolve as a universal human response to danger? Or are they culturally specific? We addressed this question by interviewing 218 warriors from the Turkana, a non-Western small-scale society, who engage in high-risk lethal cattle raids. We found that symptoms that may have evolved to protect against danger, like flashbacks and startle response, were high in the Turkana and best predicted by combat exposure. However, symptoms that are similar to depression were lower in the Turkana compared to American service members and were better predicted by moral violations. These findings suggest different evolutionary roots for different symptoms which may lead to better diagnosis and treatment. Military personnel in industrialized societies often develop posttraumatic stress disorder (PTSD) during combat. It is unclear whether combat-related PTSD is a universal evolutionary response to danger or a culture-specific syndrome of industrialized societies. We interviewed 218 Turkana pastoralist warriors in Kenya, who engage in lethal cattle raids, about their combat experiences and PTSD symptoms. Turkana in our sample had a high prevalence of PTSD symptoms, but Turkana with high symptom severity had lower prevalence of depression-like symptoms than American service members with high symptom severity. Symptoms that facilitate responding to danger were better predicted by combat exposure, whereas depressive symptoms were better predicted by exposure to combat-related moral violations. The findings suggest that some PTSD symptoms stem from an evolved response to danger, while depressive PTSD symptoms may be caused by culturally specific moral norm violations.
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Krauss SW, Zust J, Frankfurt S, Kumparatana P, Riviere LA, Hocut J, Sowden WJ, Adler AB. Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members. J Trauma Stress 2021; 34:357-366. [PMID: 33301629 DOI: 10.1002/jts.22635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Stephen W Krauss
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Jeffrey Zust
- Evangelical Lutheran Church in America, Chicago, Illinois, USA
| | - Sheila Frankfurt
- VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
- Central Texas VA Healthcare System, Temple, Texas, USA
- College of Medicine, Texas A&M University, College Station, Texas, USA
| | - Pam Kumparatana
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Lyndon A Riviere
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Joy Hocut
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Walter J Sowden
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
- Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Amy B Adler
- Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
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Maguen S, Griffin BJ, Copeland LA, Perkins DF, Finley EP, Vogt D. Gender differences in prevalence and outcomes of exposure to potentially morally injurious events among post-9/11 veterans. J Psychiatr Res 2020; 130:97-103. [PMID: 32805522 DOI: 10.1016/j.jpsychires.2020.06.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/02/2020] [Accepted: 06/24/2020] [Indexed: 11/24/2022]
Abstract
Our goal was to identify gender differences in the prevalence and outcomes of exposure to potentially morally injurious events (PMIEs) in a sample of U.S. military veterans. In a national sample of post-9/11 veterans (n = 7200) weighted to reflect the larger population of newly separated U.S. veterans, we conducted gender-stratified analyses of the prevalence of exposure to PMIEs and their associations with psychological and functional problems. Veterans reported exposures stemming from witnessing (27.9%), perpetrating (18.8%), and being betrayed (41.1%). Women more frequently reported witnessing- and betrayal-based PMIEs, but no gender differences were observed for perpetration-based PMIEs. Psychological distress was associated with witnessing and betrayal among women and with witnessing, betrayal, and perpetration among men. Whereas betrayal was most consistently associated with functional impairment across domains for women, perpetration was most consistently associated with functional impairment for men. Moral injury contributes to psychological and functional problems among a significant minority of military veterans, although effects vary based on PMIE type and gender. Implications for veterans and other populations who experience moral injury are discussed.
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Usset TJ, Gray E, Griffin BJ, Currier JM, Kopacz MS, Wilhelm JH, Harris JI. Psychospiritual Developmental Risk Factors for Moral Injury. Religions 2020; 11:484. [DOI: 10.3390/rel11100484] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is increasing theoretical, clinical, and empirical support for the hypothesis that psychospiritual development, and more specifically, postconventional religious reasoning, may be related to moral injury. In this study, we assessed the contributions of exposure to potentially morally injurious events, posttraumatic stress symptoms, and psychospiritual development to moral injury symptoms in a sample of military veterans (N = 212). Psychospiritual development was measured as four dimensions, based on Wulff’s theory juxtaposing conventional vs. postconventional levels of religious reasoning, with decisions to be an adherent or a disaffiliate of faith. After controlling for exposure to potentially morally injurious events and severity of posttraumatic stress symptoms, veterans who were conventional disaffiliates reported higher scores on the Moral Injury Questionnaire than conventional adherents, postconventional adherents, or postconventional disaffiliates. We conclude that the role of psychospiritual development offers a theoretical approach to moral injury that invites collaboration between social scientists, philosophers, theologians, and medical professionals.
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23
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Husky MM, Alvarez Fernandez V, Tapia G, Oprescu F, Navarro-Mateu F, Kovess-Masfety V. Mental disorders and medical conditions associated with causing injury or death: A population-based study. Psychiatry Res 2020; 287:112899. [PMID: 32169724 DOI: 10.1016/j.psychres.2020.112899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/23/2022]
Abstract
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.
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Griffin BJ, Purcell N, Burkman K, Litz BT, Bryan CJ, Schmitz M, Villierme C, Walsh J, Maguen S. Moral Injury: An Integrative Review. J Trauma Stress 2019; 32:350-362. [PMID: 30688367 DOI: 10.1002/jts.22362] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Brandon J Griffin
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Natalie Purcell
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Social and Behavioral Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Kristine Burkman
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Departments of Psychiatry and Psychology, Boston University, Boston, MA, USA
| | - Craig J Bryan
- National Center for Veterans Studies, The University of Utah, Salt Lake City, UT, USA.,Department of Psychology, The University of Utah, Salt Lake City, UT, USA
| | - Martha Schmitz
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Claudia Villierme
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Jessica Walsh
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
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Litz BT, Kerig PK. Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications. J Trauma Stress 2019; 32:341-349. [PMID: 31162737 DOI: 10.1002/jts.22405] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 01/29/2023]
Abstract
This article introduces a special issue of the Journal of Traumatic Stress devoted to new directions in the study of moral injury (MI), defined as transgressive harms and the outcomes of those experiences. Although a significant body of research has emerged devoted to the study of the MI construct, a number of conceptual and empirical challenges have arisen; these are summarized and discussed in the present article. In addition, this article proposes ways of overcoming these challenges in order to further research and clinical practice in the field. We then go on to introduce the content and themes of the present collection of articles in this special issue, all of which provide examples of some of the most innovative and forward-looking work on the topic and expand into new conceptual frameworks, new methods of investigation, and new populations and contexts.
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Affiliation(s)
- Brett T Litz
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Departments of Psychology and Psychiatry, Boston University, Boston, Massachusetts, USA
| | - Patricia K Kerig
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
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Griffith J. Relationships of deployment and combat experiences to postdeployment negative health conditions among Army National Guard soldiers. Military Psychology 2019. [DOI: 10.1080/08995605.2019.1565908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- James Griffith
- National Center for Veterans Studies, University of Utah, Salt Lake City, Utah
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Burkman K, Purcell N, Maguen S. Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials. J Clin Psychol 2018; 75:79-94. [PMID: 30368815 DOI: 10.1002/jclp.22702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We assessed whether treatment providers specializing in evidence-based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible. METHODS Ten providers from a large veterans administration (VA) medical center were provided with materials from IOK. We audio-recorded a semistructured interview with each provider where we elicited open-ended feedback as well as asked five structured questions about the relative advantage, compatibility, complexity/simplicity, trialability, and observability of IOK. RESULTS All providers found IOK feasible, acceptable, and something they could incorporate into their existing practice. Providers reported that the spiritual and moral concerns addressed in IOK were novel, and that self-forgiveness and making amends were critical components promoting healing from moral injury not emphasized in other treatments. CONCLUSIONS Among trauma providers, IOK was found acceptable and feasible, offering a novel approach to addressing moral injury among combat veterans.
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Affiliation(s)
- Kristine Burkman
- Department of Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
| | - Natalie Purcell
- Department of Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Social Behavioral Sciences, University of California, San Francisco, California
| | - Shira Maguen
- Department of Mental Health Service, San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, California
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Affiliation(s)
- Lauren Paige
- Department of Psychology, George Mason University, Fairfax, Virginia
| | - Keith D. Renshaw
- Department of Psychology, George Mason University, Fairfax, Virginia
| | - Elizabeth S. Allen
- Department of Psychology, University of Colorado Denver, Denver, Colorado
| | - Brett T. Litz
- VA Boston Healthcare System, Boston, Massachusetts and Department of Psychological and Brain Sciences and Department of Psychiatry, Boston University, Boston, Massachusetts
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Schorr Y, Stein NR, Maguen S, Barnes JB, Bosch J, Litz BT. Sources of moral injury among war veterans: A qualitative evaluation. J Clin Psychol 2018; 74:2203-2218. [PMID: 29984839 DOI: 10.1002/jclp.22660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 05/09/2018] [Accepted: 06/05/2018] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Yonit Schorr
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
| | | | - Shira Maguen
- San Francisco VA Medical Center, San Francisco, California.,San Francisco School of Medicine, University of California, San Francisco, California
| | - J Ben Barnes
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Jeane Bosch
- San Francisco VA Medical Center, San Francisco, California
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts.,School of Medicine, Boston University, Boston, Massachusetts
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Kelley ML, Bravo AJ, Hamrick HC, Braitman AL, Judah MR. Killing during combat and negative mental health and substance use outcomes among recent-era veterans: The mediating effects of rumination. Psychol Trauma 2018; 11:379-382. [PMID: 29963891 DOI: 10.1037/tra0000385] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although killing in combat is associated with negative mental health outcomes and hazardous alcohol use, mechanisms that underlie this risk are not well understood. To our knowledge, this present brief report is the first to use mediation analysis to examine associations between killing in combat, distinct facets of rumination (problem-focused thoughts, counterfactual thinking, repetitive thoughts, and anticipatory thoughts), and negative mental health outcomes (i.e., depression, anxiety, PTSD, suicidality) and hazardous alcohol use. METHOD Participants were a community sample of 283 military personnel (158 males [60.31%]; mean age = 32.61 [SD = 7.11]) who had deployed in support of recent wars in Iraq or Afghanistan. Participants completed an online self-report survey. RESULTS Three rumination facets (i.e., problem-focused thoughts, counterfactual thinking, and anticipatory thoughts) uniquely (controlling for effects of other rumination facets) mediated the associations between killing in combat and negative mental health outcomes and hazardous alcohol use. Taken together, killing in combat was associated with higher levels of each rumination facet, which in turn were distinctly associated with more negative symptoms of mental health and more hazardous drinking (problem-focused thoughts were the only facet to mediate all effects). Beyond these significant mediation effects, killing in combat still had a significant direct effect on every outcome. CONCLUSION These findings provide preliminary support for associations between killing in combat and negative mental health outcomes and hazardous alcohol use. Furthermore, rumination (particularly problem-focused thoughts) may be an important consideration in the evaluation and care of recent-era combat veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | - Matt R Judah
- Virginia Consortium Program in Clinical Psychology
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31
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Yalch MM, Hebenstreit CL, Maguen S. Influence of military sexual assault and other military stressors on substance use disorder and PTS symptomology in female military veterans. Addict Behav 2018; 80:28-33. [PMID: 29310004 DOI: 10.1016/j.addbeh.2017.12.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 12/21/2017] [Accepted: 12/21/2017] [Indexed: 11/24/2022]
Abstract
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.
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Lindert J, Knobler HY, Kawachi I, Bain PA, Abramowitz MZ, McKee C, Reinharz S, McKee M. Psychopathology of children of genocide survivors: a systematic review on the impact of genocide on their children`s psychopathology from five countries. Int J Epidemiol 2018; 46:246-257. [PMID: 27784741 DOI: 10.1093/ije/dyw161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 01/09/2023] Open
Abstract
Background : The health consequences of genocides on children of survivors are increasingly discussed but conclusions have been conflicting. Methods We systematically reviewed studies from five electronic databases (EMBASE, PILOTS, PUBMED, PsycINFO, Web of Science), which used a quantitative study design and included: (i) exposure to the genocides of Armenians in Nazi Germany, Cambodia, Rwanda and Bosnia; (ii) mental health outcomes; (iii) validated instruments; (iv) statistical tests of associations. Study quality was appraised using a quality assessment tool for genocide studies. PRISMA reporting guidelines were followed. Results From 3352 retrieved records, 20 studies with a total of 4793 participants involving 2431 children of survivors and 2362 controls met the eligibility criteria. Studies were conducted in seven countries: Australia, Canada, Italy, Israel, Norway, Rwanda and the USAs over the past seven decades, using the Genocide Studies Quality Assessment Tool. Data from the high quality studies provide no consistent evidence that children of genocide survivors are more likely to have mental health problems than comparators who were not children of genocide survivors. Conclusions Methodological characteristics were associated with findings: studies investigating random samples of genocide survivors did not find an impact of genocides on health of children of survivors. Potential confounders (e.g. recent life events, poverty) need further investigation. Future studies of the impact of genocides on mental health should report using a standardized structure, such as the quality tool used here.
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Affiliation(s)
- Jutta Lindert
- Department of Health and Social Work, University of Emden, Emden, Germany and Women`s Research Center, Brandeis University, Waltham, MA, USA
| | - Haim Y Knobler
- Jerusalem Mental Health Center, Hadassah Hebrew University Medical School, Jerusalem, Israel and Peres Academic Center, Rehovot, Israel
| | | | - Paul A Bain
- Countway Library, Harvard School of Public Health, Boston, MA, USA
| | - Moshe Z Abramowitz
- Jerusalem Mental Health Center, Hadassah Hebrew University Medical School, Jerusalem, Israel
| | - Charlotte McKee
- Department pf Political Sciences, Exeter University, Exeter, UK
| | - Shula Reinharz
- Women's Research Center, Brandeis University, Waltham, MA, USA
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Osório C, Jones N, Jones E, Robbins I, Wessely S, Greenberg N. Combat Experiences and their Relationship to Post-Traumatic Stress Disorder Symptom Clusters in UK Military Personnel Deployed to Afghanistan. Behav Med 2018; 44:131-140. [PMID: 28281936 DOI: 10.1080/08964289.2017.1288606] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The association of post-traumatic stress disorder (PTSD) symptom clusters with combat and other operational experiences among United Kingdom Armed Forces (UK AF) personnel who deployed to Afghanistan in 2009 were examined. Previous studies suggest that the risk of developing PTSD rises as combat exposure levels increase. To date, no UK research has investigated how specific classes of combat and operational experiences relate to PTSD symptom clusters. The current study was a secondary analysis of data derived from a two-arm cluster, randomized-controlled trial of a postdeployment operational stress-reduction intervention in deployed UK AF personnel. 2510 UK AF personnel provided combat exposure data and completed the PTSD checklist (civilian version) immediately post-deployment while 1635 of the original cohort completed further followed-up measures four to six months later. A 14-item combat experience scale was explored using principle component analysis, which yielded three main categories of experience: (1) violent combat, (2) proximity to wounding or death and (3) encountering explosive devices. The association of combat experience classes to PTSD 5-factor "dysphoric arousal" model (re-experiencing, avoidance, numbing, dysphoric-arousal and anxious-arousal symptoms) was assessed. Greater exposure to violent combat was predictive of re-experiencing and numbing symptoms, while proximity to wounding or death experiences were predictive of re-experiencing and anxious-arousal symptoms. Explosive device exposure was predictive of anxious-arousal symptoms. The present study suggests that categories of combat experience differentially impact on PTSD symptom clusters and may have relevance for clinicians treating military personnel following deployment.
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Abstract
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.
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Purcell N, Griffin BJ, Burkman K, Maguen S. "Opening a Door to a New Life": The Role of Forgiveness in Healing From Moral Injury. Front Psychiatry 2018; 9:498. [PMID: 30405451 PMCID: PMC6203131 DOI: 10.3389/fpsyt.2018.00498] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/24/2018] [Indexed: 12/03/2022] Open
Abstract
For military veterans struggling with moral injury, forgiveness can become both an animating concern and a potential path to healing. In this perspective piece, we draw on our clinical work and research findings to examine why forgiveness matters to veterans who feel guilt and shame about their actions in war, what type of forgiveness is attainable and meaningful, and what role clinicians can play in facilitating forgiveness. We conclude by reflecting on the potential, as well as the limits and tensions, of forgiveness work in the context of military moral injury.
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Affiliation(s)
- Natalie Purcell
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States.,Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Brandon J Griffin
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Kristine Burkman
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States.,Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States.,Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
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Pitts BL, Chapman P, Safer MA, Unwin B, Figley C, Russell DW. Killing Versus Witnessing Trauma: Implications for the Development of PTSD in Combat Medics. Military Psychology 2017; 25:537-44. [DOI: 10.1037/mil0000025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Schumm JA, Pukay-Martin ND, Gore WL. A Comparison of Veterans Who Repeat Versus Who Do Not Repeat a Course of Manualized, Cognitive-Behavioral Therapy for Posttraumatic Stress Disorder. Behav Ther 2017; 48:870-882. [PMID: 29029682 DOI: 10.1016/j.beth.2017.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 06/19/2017] [Accepted: 06/30/2017] [Indexed: 11/16/2022]
Abstract
Despite evidence that cognitive-behavioral therapy (CBT) for posttraumatic stress disorder (PTSD) is effective, some individuals do not experience clinically significant reduction or remission of their PTSD symptoms. These individuals may return for additional PTSD-focused psychotherapy. However, there is no research to know whether PTSD treatment repeaters have worse symptoms prior to the initial treatment episode or display differences in other pretreatment characteristics versus nonrepeaters. Research is also needed to explore whether treatment repeaters exhibit PTSD symptom changes during an initial or second course of treatment. The current study examines differences in pretreatment characteristics and treatment response among U.S. military veterans who participated in either a single course (n = 711) or in two separate courses (n = 87) of CBT for PTSD through an outpatient Veterans Affairs PTSD treatment program. Veterans completing two courses of CBT for PTSD were more likely to be married and employed and more likely to drop out of their initial course of treatment versus those who completed a single course. Hierarchical linear models showed that reductions in PTSD symptoms during treatment were not different for those who completed a second versus single course of CBT for PTSD. However, for those participating in two courses of CBT for PTSD, a relapse in PTSD symptoms was observed between the first and second course. These findings show that a second course of CBT may be viable for those with ongoing PTSD symptoms.
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Held P, Klassen BJ, Zalta AK, Pollack MH. Understanding the Impact and Treatment of Moral Injury Among Military Service Members. Focus (Am Psychiatr Publ) 2017; 15:399-405. [PMID: 31975870 DOI: 10.1176/appi.focus.20170023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.
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Affiliation(s)
- Philip Held
- Dr. Held, Dr. Klassen, Dr. Zalta, and Dr. Pollack are with the Department of Psychiatry, Rush University Medical Center, Chicago. Dr. Zalta is also with the Department of Behavioral Sciences, Rush University Medical Center, Chicago
| | - Brian J Klassen
- Dr. Held, Dr. Klassen, Dr. Zalta, and Dr. Pollack are with the Department of Psychiatry, Rush University Medical Center, Chicago. Dr. Zalta is also with the Department of Behavioral Sciences, Rush University Medical Center, Chicago
| | - Alyson K Zalta
- Dr. Held, Dr. Klassen, Dr. Zalta, and Dr. Pollack are with the Department of Psychiatry, Rush University Medical Center, Chicago. Dr. Zalta is also with the Department of Behavioral Sciences, Rush University Medical Center, Chicago
| | - Mark H Pollack
- Dr. Held, Dr. Klassen, Dr. Zalta, and Dr. Pollack are with the Department of Psychiatry, Rush University Medical Center, Chicago. Dr. Zalta is also with the Department of Behavioral Sciences, Rush University Medical Center, Chicago
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Korinek K, Loebach P, Teerawichitchainan B. Physical and Mental Health Consequences of War-related Stressors Among Older Adults: An Analysis of Posttraumatic Stress Disorder and Arthritis in Northern Vietnamese War Survivors. J Gerontol B Psychol Sci Soc Sci 2017; 72:1090-1102. [PMID: 26758194 DOI: 10.1093/geronb/gbv157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 12/10/2015] [Indexed: 12/14/2022] Open
Abstract
Objectives We examine the impacts of trauma exposures and family stressors associated with the Vietnam War on musculoskeletal health and posttraumatic stress disorder (PTSD) outcomes in elderly Vietnamese who were widely impacted by the war as young adults. Noting that wars' impacts extend beyond male veterans in most survivor populations, we give attention to male and female war survivors placed in a variety of roles vis-a-vis the war. Method Utilizing data from the 2010 Vietnam Health and Aging Pilot Study (N = 405), we use logistic and Poisson regression models to estimate the effect of wartime trauma exposures and family stressors on disabling arthritis and PTSD symptoms in male and female northern Vietnamese adults aged 55 and older. Results The odds of experiencing recent PTSD symptoms are greater in respondents who report involvement in killing/causing severe injury and who observed war atrocities. In women, PTSD is positively correlated with war era child death and spousal separation. Arthritis also exhibits a significant, positive association with killing/causing severe injury. Discussion Our study provides insights into the burden of conflict upon health among populations of the global south that survived war and are now entering older adulthood. The pattern of results, indicating greatest suffering among those who inflicted or failed to prevent bodily harm or loss of life, is consistent with the concept of moral injury.
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Affiliation(s)
- Kim Korinek
- Department of Sociology, University of Utah, Salt Lake City
| | - Peter Loebach
- Department of Sociology and Anthropology, Weber State University, Ogden, Utah
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Held P, Boley RA, Karnik NS, Pollack MH, Zalta AK. Characteristics of veterans and military service members who endorse causing harm, injury, or death to others in the military. Psychol Trauma 2017; 10:352-359. [PMID: 28758768 DOI: 10.1037/tra0000294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The purpose of the present research was to examine the demographic and mental health characteristics of veterans and service members who endorsed having caused harm, injury, or death to another person on deployment, while taking these individuals' total number of other lifetime traumas into account. METHOD Data for the present study were collected as part of the standard clinical evaluation for 228 treatment-seeking veterans and service members. RESULTS Those who reported having caused harm, injury, or death to another person on deployment (22.4%) were more likely to be male, to have served in the Marines, to have served post 9/11, and to endorse other traumas commonly reported on deployment than those who did not endorse causing harm, injury, or death. Those who endorsed causing harm on deployment were less likely to have served in the Air Force, and to have experienced sexual assault than those who did not cause harm. Causing harm, injury, or death was associated with higher levels of posttraumatic stress disorder (PTSD), drug use, and expressive anger at the bivariate level, but was no longer associated with mental health problems after accounting for the number of other lifetime traumas. CONCLUSIONS Examining the role of causing harm in isolation may lead to false conclusions. Clinicians and researchers should assess for veterans' and service members' entire trauma histories. (PsycINFO Database Record
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Affiliation(s)
- Philip Held
- Department of Psychiatry, Rush University Medical Center
| | - Randy A Boley
- Department of Psychiatry, Rush University Medical Center
| | | | - Mark H Pollack
- Department of Psychiatry, Rush University Medical Center
| | - Alyson K Zalta
- Department of Psychiatry, Rush University Medical Center
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Steenkamp MM, Schlenger WE, Corry N, Henn-Haase C, Qian M, Li M, Horesh D, Karstoft KI, Williams C, Ho CL, Shalev A, Kulka R, Marmar C. Predictors of PTSD 40 years after combat: Findings from the National Vietnam Veterans longitudinal study. Depress Anxiety 2017; 34:711-722. [PMID: 28489300 DOI: 10.1002/da.22628] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 01/27/2017] [Accepted: 02/06/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Few studies have longitudinally examined predictors of posttraumatic stress disorder (PTSD) in a nationally representative sample of US veterans. We examined predictors of warzone-related PTSD over a 25-year span using data from the National Vietnam Veterans Longitudinal Study (NVVLS). METHODS The NVVLS is a follow-up study of Vietnam theater veterans (N = 699) previously assessed in the National Vietnam Veterans Readjustment Study (NVVRS), a large national-probability study conducted in the late 1980s. We examined the ability of 22 premilitary, warzone, and postmilitary variables to predict current warzone-related PTSD symptom severity and PTSD symptom change in male theater veterans participating in the NVVLS. Data included a self-report Health Questionnaire survey and a computer-assisted telephone Health Interview Survey. Primary outcomes were self-reported PTSD symptoms assessed by the PTSD Checklist for DSM-5 (PCL 5) and Mississippi PTSD Scale (M-PTSD). RESULTS Predictors of current PTSD symptoms most robust in hierarchical multivariable models were African-American race, lower education level, negative homecoming reception, lower current social support, and greater past-year stress. PTSD symptoms remained largely stable over time, and symptom exacerbation was predicted by African-American race, lower education level, younger age at entry into Vietnam, greater combat exposure, lower current social support, and greater past-year stressors. CONCLUSIONS Findings confirm the robustness of a select set of risk factors for warzone-related PTSD, establishing that these factors can predict PTSD symptom severity and symptom change up to 40 years postdeployment.
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Affiliation(s)
- Maria M Steenkamp
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | | | | | - Clare Henn-Haase
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | - Meng Qian
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | - Meng Li
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | - Danny Horesh
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | - Karen-Inge Karstoft
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | | | | | - Arieh Shalev
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
| | | | - Charles Marmar
- Department of Psychiatry, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, NYU Langone Medical Center, New York, NY, USA
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Wisco BE, Marx BP, May CL, Martini B, Krystal JH, Southwick SM, Pietrzak RH. Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depress Anxiety 2017; 34:340-347. [PMID: 28370818 DOI: 10.1002/da.22614] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 01/31/2017] [Accepted: 02/17/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Combat exposure is associated with increased risk of mental disorders and suicidality. Moral injury, or persistent effects of perpetrating or witnessing acts that violate one's moral code, may contribute to mental health problems following military service. The pervasiveness of potentially morally injurious events (PMIEs) among U.S. combat veterans, and what factors are associated with PMIEs in this population remains unknown. METHODS Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, including 564 combat veterans, collected September-October 2013. Types of PMIEs (transgressions by self, transgressions by others, and betrayal) were assessed using the Moral Injury Events Scale. Psychiatric and functional outcomes were assessed using established measures. RESULTS A total of 10.8% of combat veterans acknowledged transgressions by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PMIEs were moderately positively associated with combat severity (β = .23, P < .001) and negatively associated with white race, college education, and higher income (βs = .11-.16, Ps < .05). Transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with postdeployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity. CONCLUSIONS A significant minority of U.S combat veterans report PMIEs related to their military service. PMIEs are associated with risk for mental disorders and suicidality, even after adjustment for sociodemographic variables, trauma and combat exposure histories, and past psychiatric disorders.
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Affiliation(s)
- Blair E Wisco
- Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC
| | - Brian P Marx
- U.S. Department of Veterans Affairs National Center for PTSD, VA Boston Healthcare System, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Casey L May
- Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC
| | - Brenda Martini
- U.S. Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, CT, USA
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA
| | - John H Krystal
- U.S. Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, CT, USA
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA
| | - Steven M Southwick
- U.S. Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, CT, USA
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA
| | - Robert H Pietrzak
- U.S. Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, CT, USA
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA
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Maguen S, Burkman K, Madden E, Dinh J, Bosch J, Keyser J, Schmitz M, Neylan TC. Impact of Killing in War: A Randomized, Controlled Pilot Trial. J Clin Psychol 2017; 73:997-1012. [DOI: 10.1002/jclp.22471] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 11/10/2016] [Accepted: 01/29/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Shira Maguen
- San Francisco VA Medical Center
- University of California; San Francisco
| | - Kristine Burkman
- San Francisco VA Medical Center
- University of California; San Francisco
| | | | | | | | - Jessica Keyser
- San Francisco VA Medical Center
- University of California; San Francisco
| | - Martha Schmitz
- San Francisco VA Medical Center
- University of California; San Francisco
| | - Thomas C. Neylan
- San Francisco VA Medical Center
- University of California; San Francisco
- Mental Illness Research; Education & Clinical Center
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Abstract
Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It describes the consequences that veterans identify as most relevant in their lives, including postwar changes in emotions, cognitions, relationships, and identity. Furthermore, it illustrates the linked psychological and social dimensions of those consequences—namely, how the impact of killing in war is rooted in the unique perspectives, actions, and experiences of individual veterans, as well as the social worlds they confront upon returning from war. We found that, for many veterans, killing provokes a moral conflict with a lasting impact on their sense of self, spirituality, and relationships with others. In working with combat veterans, mental health professionals should be sensitive to the complexities of discussing killing and attuned to the psychosocial challenges veterans may face after taking a life in war.
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Affiliation(s)
- Natalie Purcell
- University of California, San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Christopher J. Koenig
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- San Francisco State University, San Francisco, CA, USA
| | | | - Shira Maguen
- University of California, San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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Weiss NH, Duke AA, Overstreet NM, Swan SC, Sullivan TP. Intimate partner aggression-related shame and posttraumatic stress disorder symptoms: The moderating role of substance use problems. Aggress Behav 2016; 42:427-40. [PMID: 26699821 DOI: 10.1002/ab.21639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 11/11/2022]
Abstract
A dearth of literature has examined the consequences of women's use of aggression in intimate relationships. Women's use of aggression against their intimate partners, regardless of their motivation (e.g., self-defense, retaliation), may elicit shame. Shame, in turn, may contribute to the maintenance and/or exacerbation of posttraumatic stress disorder (PTSD) symptoms, which are commonly experienced in this population. Further, emerging research suggests that emotionally avoidant coping strategies, such as substance use, may strengthen the relation between shame and PTSD symptoms. The goal of the present study was to examine whether women's shame concerning their use of intimate partner aggression is associated with their PTSD symptoms, and whether drug and alcohol use problems moderate this association. Participants were 369 community women who had used and been victimized by physical aggression in an intimate relationship with a male partner in the past six months. The intimate partner aggression-related shame × drug (but not alcohol) use problems interaction on PTSD symptom severity was significant. Analysis of simple slopes revealed that women's intimate partner aggression-related shame was positively associated with their PTSD symptoms when drug use problems were high, but not when drug use problems were low. Findings have implications for the potential utility of PTSD treatments targeting a reduction in shame and maladaptive shame regulation strategies (i.e., drug use) in this population. Aggr. Behav. 42:427-440, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Nicole H. Weiss
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut
| | - Aaron A. Duke
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut
| | | | - Suzanne C. Swan
- Department of Psychology; University of South Carolina; Columbia South Carolina
| | - Tami P. Sullivan
- Department of Psychiatry; Yale University School of Medicine; New Haven Connecticut
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Tobón C, Aguirre-Acevedo DC, Velilla L, Duque J, Ramos CP, Pineda D. [Psychiatric, Cognitive and Emotional Profile in Ex-combatants of Illegal Armed Groups in Colombia]. Rev Colomb Psiquiatr 2016; 45:28-36. [PMID: 26896402 DOI: 10.1016/j.rcp.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 06/01/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Exposure to armed conflict produces biological adaptations oriented to handle the highly stressful conditions in war environments. The special features of The Colombian armed create a special scenario to evaluate the human behavior. OBJECTIVE In this study, psychiatric, cognitive and emotional processing characteristics of a group of Colombian armed illegal forces of ex-combatants are described. METHODS Sixty-three ex combatants and 22 controls were assessed with WAIS (IQ), INECO frontal screening (executive functions), Interpersonal Reactivity Index (empathy), emotional features recognition and MINI (psychiatric profile). RESULTS When compared to the control group, ex-combatants showed higher frequency of antisocial personality disorder (P=.031) and behavioral dissocial disorder (P=.017). In cognitive profile, the ex-combatants showed a lower score in the executive function test (Me=18.50; RQ=4.00), control (Me=23.00; RQ=5.25), with a poor personal distress in emphatic profile (Me=10.00; RQ=5.00) compared to control group (Me=37.00; RQ=7.25). CONCLUSIONS We found differences in cognitive and psychiatric profile in ex-combatants in comparison with controls.
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Affiliation(s)
- Carlos Tobón
- Grupo de Neurociencias de Antioquia, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia; Grupo de Neuropsicología y Conducta, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia
| | | | - Lina Velilla
- Grupo de Neurociencias de Antioquia, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia
| | - Jon Duque
- Grupo de Neurociencias de Antioquia, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia; Grupo de Investigación en Bioinstrumentación en Ingeniería Clínica, Facultad de Ingeniería, Universidad de Antioquia UDEA, Medellín, Colombia
| | - Claudia Patricia Ramos
- Grupo de Neuropsicología y Conducta, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia
| | - David Pineda
- Grupo de Neurociencias de Antioquia, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia; Grupo de Neuropsicología y Conducta, Facultad de Medicina, Universidad de Antioquia UDEA, Medellín, Colombia.
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Köbach A, Nandi C, Crombach A, Bambonyé M, Westner B, Elbert T. Violent Offending Promotes Appetitive Aggression Rather than Posttraumatic Stress-A Replication Study with Burundian Ex-Combatants. Front Psychol 2015; 6:1755. [PMID: 26696913 PMCID: PMC4672083 DOI: 10.3389/fpsyg.2015.01755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 11/02/2015] [Indexed: 11/13/2022] Open
Abstract
Research has identified appetitive aggression, i.e., the perception of committed, violent acts as appealing, exciting and fascinating, as a common phenomenon within populations living in precarious and violent circumstances. Investigating demobilized soldiers in the Democratic Republic of Congo (DRC) demonstrated that violent offending is associated with appetitive aggression and not necessarily with symptoms of posttraumatic stress. In the present study, we sought to replicate these results in an independent and larger sample of demobilized soldiers from Burundi. As with the Congolese ex-combatants, random forest regression revealed that the number of lifetime perpetrated violent acts is the most important predictor of appetitive aggression and the number of lifetime experienced traumatic events is the main predictor for posttraumatic stress. Perpetrated violent acts with salient cues of hunting (pursuing the victim, the sight of blood, etc.) were most predictive for perceiving violent cues appealingly after demobilization. Moreover, the association of violent acts and appetitive aggression as well as traumatic events and posttraumatic stress remains strong even years after demobilization. Patterns of traumatic events and perpetrated acts as predictors for posttraumatic stress and appetitive aggression seem to be robust among different samples of ex-combatants who fought in civil wars. Psychotherapeutic interventions that address these complementary facets of combat-related disorders—namely, posttraumatic stress and appetitive aggression—are indispensable for a successful reintegration of those who fought in armed conflicts and to achieve a successful transition to peace.
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Affiliation(s)
- Anke Köbach
- Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International Konstanz, Germany
| | - Corina Nandi
- Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany
| | - Anselm Crombach
- Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International Konstanz, Germany ; Department of Clinical Psychology, Université Lumière de Bujumbura Bujumbura, Burundi
| | - Manassé Bambonyé
- Department of Clinical Psychology, Université Lumière de Bujumbura Bujumbura, Burundi
| | - Britta Westner
- Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany
| | - Thomas Elbert
- Clinical and Neuropsychology Group, Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International Konstanz, Germany ; Department of Clinical Psychology, Université Lumière de Bujumbura Bujumbura, Burundi
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Köbach A, Schaal S, Elbert T. Combat high or traumatic stress: violent offending is associated with appetitive aggression but not with symptoms of traumatic stress. Front Psychol 2015; 5:1518. [PMID: 25709586 PMCID: PMC4285743 DOI: 10.3389/fpsyg.2014.01518] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/09/2014] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Anke Köbach
- Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International ( www.vivo.org )
| | - Susanne Schaal
- Vivo International ( www.vivo.org ) ; Department of Psychology, University of Ulm Ulm, Germany
| | - Thomas Elbert
- Department of Psychology, University of Konstanz Konstanz, Germany ; Vivo International ( www.vivo.org )
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