/pdf/invisible-wounds-of-war-psychological-and-cognitive-injuries-30tq5543fu.pdf

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences and Services to Assist Recovery

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.

Moral Injury: An Integrative Review

Here is a book that I would never have read outside this assignment. Yet, reading it has been a delightful and informative experience. Homer's Iliad tells the tragedy of the ancient Greek soldier Achilles in the Trojan War. In this book, Vietnam veterans have narrated their own tragedies. Twenty-two years after the last US ground combat battalion was withdrawn, more than 250 000 Vietnam combat veterans currently meet the full DSM-IV criteria for posttraumatic stress disorder (PTSD). Achilles in Vietnam compares and contrasts two wars separated by 27 centuries. Dr Shay is a Boston-area psychiatrist who works with Vietnam combat veterans in the Department of Veterans Affairs Outpatient Clinic. He is also on the faculty of Tufts University School of Medicine. His purpose in writing this book is "to put before the public an understanding of the specific nature of catastrophic war experiences that not only cause lifelong disabling psychiatric

Achilles in Vietnam: Combat Trauma and the Undoing of Character

FIGURE 1 AND COVER. Recent studies have begun to explore how the underlying neurobiology of posttraumatic stress disorder (PTSD) may be affected by the nature of the index trauma. The results of a meta-analysis that grouped task-activated (trauma reminders) functional MRI (fMRI) studies by PTSD index trauma are color-coded by trauma type (blue, sexual/physical abuse; pink, combat-related) (1). Of note, although areas of greater activation were predominately in the right hemisphere for both groups, there was little or no overlap. One study has compared resting-state regional cerebral metabolic rate between veterans with PTSD grouped by whether the index trauma was dangerand/or fear-based (i.e., life threat to self or other) or nondanger-based (i.e., witnessing violence, traumatic loss, moral injury by self or other). Regions of interest (ROIs) (yellow circles) were areas previously reported to be activated by fear stimuli (bilateral amygdalae, right rostral anterior cingulate cortex) or by traumatic script imagery (right dorsal anterior cingulate cortex, left posterior cingulate cortex, left precuneus). Dangerand/or fear-based traumas were associated with higher metabolism in the amygdala (red fill), whereas nondanger-based traumas were associated with higher metabolism in the precuneus (green fill). As noted by the authors, heightened metabolism in the precuneus for nondanger-based traumas may relate to its role in self-referential processing (2). Moral injury often co-occurs with PTSD. Moral injuries that are index traumas for PTSD are more strongly associated with emotions that developed after the event than emotions experienced during the event, suggesting that the underlying neurobiology may differ (3). An fMRI study of military veterans has explored relationships between resting-state activity (amplitude of low frequency fluctuation [ALFF]) and symptoms of PTSD (Clinician Administered PTSD Scale [CAPS]) and moral injury (Moral Injury Events Scale [MIES]) (4). CAPS score was not significantly correlated with average ALFF in any ROI. Both subscales of the MIES (transgressions, betrayals) correlated with left inferior parietal lobule ROI activity (purple circle) but in opposite directions (Cover). As discussed by the authors, these results indicate that the neural correlates of PTSD and moral injury differ at least in part (4).

Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different

Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.

Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review

Objective
The purpose of this pilot study was to test the effectiveness of Impact of Killing (IOK), a novel, cognitive-behavioral treatment (CBT) aimed at reducing mental health symptoms and functional impairment.

Method
Participants were 33 combat Veterans with a posttraumatic stress disorder (PTSD) diagnosis who had completed trauma-focused psychotherapy and reported distress regarding killing or feeling responsible for the deaths of others in war. Veterans were randomized to either IOK treatment or a 6-week waitlist condition, after which Veterans could receive IOK. IOK is a 6- to 8-session, weekly, individual, CBT, lasting 60–90 minutes, and focused on key themes, including physiology of killing responses, moral injury, self-forgiveness, spirituality, making amends, and improved functioning.

Results
We found that compared to controls (N = 16), the IOK group (N = 17) experienced a significant improvement in PTSD symptoms, general psychiatric symptoms, and quality of life functional measures. Veterans who received IOK reported that the treatment was acceptable and feasible.

Conclusion
These results provide preliminary evidence that Veterans can benefit from a treatment focused on the impact of killing after initial trauma therapy.

Impact of Killing in War: A Randomized, Controlled Pilot Trial.

This paper evaluates the Impact of Killing (IOK) treatment—a psychological intervention designed to address moral injury and trauma associated with killing in war. Using qualitative data from inter...

https://www.tandfonline.com/doi/pdf/10.1080/10926771.2018.1463582

Jessica Keyser

Papers

Impact of Killing in War: A Randomized, Controlled Pilot Trial.

Healing from moral injury: a qualitative evaluation of the impact of Killing Treatment for combat veterans