Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach

Abstract

Background: Moral Injury (MI) is one of the adverse consequences of combat. Following exposure to potentially morally injurious events (PMIEs)--events perceived as violations of deep moral beliefs by oneself or trusted individuals--a significant minority of veterans could develop posttraumatic stress disorder (PTSD) and depression. Objective: The current study represents the first attempt to apply a network analysis model to examine an exploratory empirical conceptualization of a network of PMIEs during military service, post-traumatic stress disorder (PTSD) symptom clusters, depression, and combat exposure among Israel Defence Forces veterans. Method: A volunteer sample of 191 Israeli combat veterans were recruited during 2017, and completed validated self-report questionnaires tapping PMIEs, PTSD, and depression in a cross-sectional design study. A regularized Gaussian graphical model was estimated. Results: Network analysis revealed strong bridge associations between the PTSD nodes and most of the PMIEs nodes. The nodes of PMIE-betrayal and PTSD negative alterations in cognitions and mood (NACM) symptom cluster were found to have a bridging function between other PMIEs and PTSD. Depression was found to be connected to most of the PMIEs and PTSD nodes. Conclusions: The study's findings offer an overview of the complex relationships between PMIEs and PTSD clusters among Israeli veterans. PMIEs--notably, betrayal-based experiences--are related to PTSD clusters directly and through depressive symptoms. Some possible mechanisms for the links between PMIEs and PTSD and the clinical implications related to specific interventions are discussed. ARTICLE HISTORY

Causal discovery identifies posttraumatic stress as a driver of internalizing symptoms across independent veteran and civilian populations

“…Instead, our results suggest these symptoms represent a downstream outcome of PTSD, which may be addressed through treating features bridging between posttraumatic stress and internalizing concerns. Consistent with our exploratory analysis of potential mechanisms, a study of Israeli veterans suggested centrality of the DSM-V NACM symptom cluster in bridging among PTSD, depressive symptoms, and moral injury (25).…”

“…Instead, our results suggest these symptoms represent a downstream outcome of PTSD, which may be addressed through treating features bridging between posttraumatic stress and internalizing concerns. Consistent with our exploratory analysis of potential mechanisms, a study of Israeli veterans suggested centrality of the DSM-V NACM symptom cluster in bridging among PTSD, depressive symptoms, and moral injury (25). Similarly, consistent with our findings on the centrality of hyperarousal across PTSD and depressive symptom groups, other research suggests anxiety sensitivity and avoidance of inner experiences broadly may be transdiagnostic processes underlying PTSD and internalizing symptomatology (32,68,69).…”

“…Many clinical studies of PTSD exclude patients with internalizing comorbidities, or treat such symptoms as confounded, while studies of internalizing disorders often exclude patients with PTSD, or neglect to evaluate traumatic history (20). Cross-sectional studies have identified shared features of PTSD and other internalizing concerns (21)(22)(23)(24)(25), including network analyses using an adult cohort with depressive symptoms and trauma history, which found that impaired concentration, sleep problems, irritability, and guilt, were shared across disorders (26). Other cross-sectional analyses suggest a negative affectivity factor explains covariance across PTSD, generalized anxiety, and major depression (27,28), and indicate common genetic and environmental correlates of these concerns (29).…”

Moral Injury: An Increasingly Recognized and Widespread Syndrome

“…Research indicates that MI is also common among the active duty armed forces of other countries as well (Battaglia et al, 2019 ; Ferrajão & Aragão Oliveira, 2016 ; Levi-Belz et al, 2020 ; Williamson et al, 2021 ). For example, Hodgson et al ( 2021 ) note the high prevalence of potentially morally injurious events (PMIEs) in a qualitative study of ten Australian Veterans, identifying seven common themes giving rise to MI symptoms: immoral acts (witnessed and perpetrated), death and injury (witnessed and perpetrated), betrayal (by others and self), ethical dilemmas (humanization/dehumanization and decision-making), disproportionate violence, retribution, and religious/spiritual issues.…”

Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach

“…The most studied link that has been found is with posttraumatic stress disorder (PTSD; Koenig, Youssef, & Pearce, 2019). Other studies have also documented direct associations with depressive symptoms (Levi-Belz, Greene, & Zerach, 2020), and destructive behaviours such as substance abuse (Currier et al, 2015) and suicidality (Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014). Indeed, a recent review (Griffin et al, 2019) and a metaanalysis (Williamson, Stevelink, & Greenberg, 2018) found consistent associations between a PMIE and mental health outcomes such as PTSD, depression and suicidality, as well as other negative religious/spiritual sequelae.…”