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

Abstract

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 danger-and/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). Danger-and/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).

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

“…These findings provide an overview of the complex comorbid relationships between PMIEs and PTSD symptoms. Whereas controversy regarding the relationships between PMIEs and PTSD (Barnes et al, 2019) remains, in our sample, MI-betrayal was found to be associated with the PTSD network through the NACM cluster. The strongest bridge edges were manifested between the MI-betrayal experience and the NACM cluster (See the bootstrapped centrality stability in the supplementary material).…”

“…A growing body of empirical evidence has indicated a direct association between PMIEs and PTSD symptoms, which may explain some of the high variability in the prevalence of PTSD among combatants, such as disease course and response to therapeutic interventions (Barnes, Hurley, & Taber, 2019;Steenkamp, Litz, Hoge, & Marmar, 2015). For example, recent studies found associations between perpetration and betrayal-based PMIEs and PTSD among active-duty Marines deployed to Afghanistan (Jordan et al, 2017) and among veterans from military conflicts in Iraq and Afghanistan (Currier et al, 2015).…”

The Role of Moral Injury in PTSD Among Law Enforcement Officers: A Brief Report

“…Practically, questions remain regarding best practices for treating moral injury and the extent to which current treatments for PTSD are suitable to treat moral injury (e.g. Barnes et al, 2019;Griffin et al, 2019;Neria and Pickover, 2019) or if new treatments designed specifically for moral injury would be more efficacious (e.g. Jordan et al, 2017).…”

The Impact of Posttraumatic Stress Disorder and Moral Injury on Women Veterans’ Perinatal Outcomes Following Separation From Military Service

“…Another potential consequence of both traumatic experiences, such as MST and combat, and nontraumatic experiences, including leadership failures and/or betrayal by peers, the military, or the government, is moral injury, which may result when individuals are confronted with events that violate their sense of right and wrong and lead to reactions including shame, guilt, and demoralization (Drescher, Foy, Kelly, Leshner, Schutz, & Litz, 2011; Frankfurt & Frazier, 2016). Although some researchers conceptualize moral injury as an exposure defined by committing or participating in transgressive acts (Frankfurt & Frazier, 2016), a growing body of research indicates that what is captured by the most widely used measure of moral injury, the Moral Injury Events Scale (MIES), may be better conceptualized as an outcome of exposure to these transgressions (Barnes, Hurley, & Taber, 2019), reflecting moral pain (e.g., guilt and shame) resulting from these experiences (Richardson et al., 2019). Although moral injury and PTSD often co‐occur, theoretical models of these two conditions differ (Litz et al., 2009) and have been shown to tap unique neural correlates (Barnes et al., 2019).…”

“…Although some researchers conceptualize moral injury as an exposure defined by committing or participating in transgressive acts (Frankfurt & Frazier, 2016), a growing body of research indicates that what is captured by the most widely used measure of moral injury, the Moral Injury Events Scale (MIES), may be better conceptualized as an outcome of exposure to these transgressions (Barnes, Hurley, & Taber, 2019), reflecting moral pain (e.g., guilt and shame) resulting from these experiences (Richardson et al., 2019). Although moral injury and PTSD often co‐occur, theoretical models of these two conditions differ (Litz et al., 2009) and have been shown to tap unique neural correlates (Barnes et al., 2019). Posttraumatic stress disorder and its’ subsequent treatments are born from etiological models that primarily conceptualize PTSD as a fear‐based disorder, whereas moral injury encompasses constructs such as self‐blame and spiritual or existential issues that occur following witnessing or participating in events that conflict with deeply held moral beliefs (Litz et al., 2009).…”