A Critical Outlook on Combat-Related PTSD: Review and Case Reports of Guilt and Shame as Drivers for Moral Injury

References

• Austin, W. (2012). Moral distress and the contemporary plight of health professionals. Hec Forum, 24(1), 27–38. doi:10.1007/s10730-012-9179-8
   PubMedGoogle Scholar
• Bolton, E. E., Litz, B. T., Britt, T. W., Adler, A., & Roemer, L. (2001). Reports of prior exposure to potentially traumatic events and PTSD in troops poised for deployment. Journal of Traumatic Stress, 14(1), 249–256. doi:10.1023/A:1007864305207
   Web of Science ®Google Scholar
• Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154. doi:10.1037/h0099852
   Google Scholar
• Bryan, C. J., Morrow, C. E., Etienne, N., & Ray‐Sannerud, B. (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety, 30(1), 55–60. doi:10.1002/da.22002
   PubMed Web of Science ®Google Scholar
• Campbell, J. S. (2016). Development of the military compass of shame scale. Military Behavioral Health, 4(2), 159–167. doi:10.1080/21635781.2015.1133346
   Google Scholar
• Castro, C. A., & McGurk, D. (2007). Battlefield ethics. Traumatology, 13(4), 24. doi:10.1177/1534765607309951
   Google Scholar
• Clifton, E. G., Feeny, N. C., & Zoellner, L. A. (2017). Anger and guilt in treatment for chronic posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 54, 9–16. doi:10.1016/j.jbtep.2016.05.003
   PubMed Web of Science ®Google Scholar
• Currier, J. M., Holland, J. M., & Malott, J. (2015). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71(3), 229–240. doi:10.1002/jclp.22134
   PubMed Web of Science ®Google Scholar
• Dalgleish, T. (2004). Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing. Psychological Bulletin, 130(2), 228–260. doi:10.1037/0033-2909.130.2.228
   PubMed Web of Science ®Google Scholar
• Decker, L. R. (2007). Combat trauma: Treatment from a mystical/spiritual perspective. Journal of Humanistic Psychology, 47(1), 30–53. doi:10.1177/0022167806293000
   Web of Science ®Google Scholar
• Dennis, P. A., Dennis, N. M., Van Voorhees, E. E., Calhoun, P. S., Dennis, M. F., & Beckham, J. C. (2016). Moral transgression during the Vietnam War: A path analysis of the psychological impact of veterans' involvement in wartime atrocities. Anxiety Stress Coping, 30(2),188–201. doi:10.1080/10615806.2016.1230669
   PubMed Web of Science ®Google Scholar
• Ehlers, A., & Steil, R. (1995). Maintenance of intrusive memories in posttraumatic stress disorder: A cognitive approach. Behavioural and cognitive psychotherapy, 23(3), 217–249.
   Google Scholar
• Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249.
   Google Scholar
• Fontana, A., & Rosenheck, R. (2004). Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. The Journal of Nervous and Mental Disease, 192(9), 579–584. doi:10.1097/01.nmd.0000138224.17375.55
   PubMed Web of Science ®Google Scholar
• de Graaff, M. C., Schut, M., Verweij, D. E., Vermetten, E., & Giebels, E. (2016). Emotional reactions and moral judgment: The effects of morally challenging interactions in military operations. Ethics & Behavior, 26(1), 14–31. doi:10.1080/10508422.2014.975815
   Web of Science ®Google Scholar
• Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., & Litz, B. T. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43(2), 407–415. doi:10.1016/j.beth.2011.09.001
   PubMed Web of Science ®Google Scholar
• Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. doi:10.1016/j.brat.2005.06.006
   PubMed Web of Science ®Google Scholar
• Haagen, J. F., Smid, G. E., Knipscheer, J. W., & Kleber, R. J. (2015). The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clinical Psychology Review, 40, 184–194. doi:10.1016/j.cpr.2015.06.008
   PubMed Web of Science ®Google Scholar
• Harris, J. I., Erbes, C. R., Engdahl, B. E., Thuras, P., Murray‐Swank, N., Grace, D., … Malec, C. (2011). The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to trauma. Journal of Clinical Psychology, 67(4), 425–438. doi:10.1002/jclp.20777
   PubMed Web of Science ®Google Scholar
• Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. The American Journal of Psychiatry, 148(5), 586. doi:10.1176/ajp.148.5.586
   PubMed Web of Science ®Google Scholar
• Henning, K. R., & Frueh, B. C. (1997). Combat guilt and its relationship to PTSD symptoms. Journal of Clinical Psychology, 53(8), 801–808. doi:10.1002/(SICI)1097-4679(199712)53:8%3c801::AID-JCLP3%3e3.0.CO;2-I
   PubMed Web of Science ®Google Scholar
• Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. New England Journal of Medicine, 351, 13–22. doi:10.1056/NEJMoa040603
   PubMed Web of Science ®Google Scholar
• Kienzler, H. (2008). Debating war-trauma and post-traumatic stress disorder (PTSD) in an interdisciplinary arena. Social Science & Medicine, 67(2), 218–227. doi:10.1016/j.socscimed.2008.03.030
   PubMed Web of Science ®Google Scholar
• King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A., Robinson, E., … Liberzon, I. (2013). A pilot study of group mindfulness‐based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depression and Anxiety, 30(7), 638–645. doi:10.1002/da.22104
   PubMed Web of Science ®Google Scholar
• Kubany, E. S. (1994). A cognitive model of guilt typology in combat-related PTSD. Journal of Traumatic Stress, 7(1), 3–19. doi:10.1002/jts.2490070103
   PubMed Web of Science ®Google Scholar
• Kubany, E. S., & Manke, F. P. (1995). Cognitive therapy for trauma-related guilt: Conceptual bases and treatment outlines. Cognitive and Behavioral Practice, 2(1), 27–61.
   Google Scholar
• Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. doi:10.1016/j.cpr.2009.07.003
   PubMed Web of Science ®Google Scholar
• Maddrell, A. (2013). Moving and being moved: More-than-walking and talking on pilgrimage walks in the Manx landscape. Culture and Religion, 14(1), 63–77. doi:10.1080/14755610.2012.756409
   Google Scholar
• Maguen, S., Metzler, T. J., Litz, B. T., Seal, K. H., Knight, S. J., & Marmar, C. R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22(5), 435–443. doi:10.1002/jts.20451
   PubMed Web of Science ®Google Scholar
• Marx, B. P., Foley, K. M., Feinstein, B. A., Wolf, E. J., Kaloupek, D. G., & Keane, T. M. (2010). Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses. Depress. Anxiety, 27, 287–293. doi:10.1002/da.20659
   PubMed Web of Science ®Google Scholar
• Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16(4), 365–375. doi:10.1007/s10567-013-0146-y
   PubMed Web of Science ®Google Scholar
• Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652.
   Google Scholar
• NATO technical report on moral decisions in military operations and mental health. (2016). https://www.sto.nato.int/search/Pages/activities_results.aspx?k=moral%20decisions&s=Search%20Activities.
   Google Scholar
• Nazarov, A., Jetly, R., McNeely, H., Kiang, M., Lanius, R., & McKinnon, M. C. (2015). Role of morality in the experience of guilt and shame within the armed forces. Acta Psychiatrica Scandinavica, 132(1), 4–19. doi:10.1111/acps.12406
   PubMed Web of Science ®Google Scholar
• Norris, F. H. (1992). Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of consulting and clinical psychology, 60(3), 409. doi:10.1037/0022-006X.60.3.409
   PubMed Web of Science ®Google Scholar
• Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129. doi:10.1177/0145445504270876
   PubMed Web of Science ®Google Scholar
• Paul, L. A., Gros, D. F., Strachan, M., Worsham, G., Foa, E. B., & Acierno, R. (2014). Prolonged exposure for guilt and shame in a veteran of Operation Iraqi Freedom. American Journal of Psychotherapy, 68(3), 277–286.
   PubMedGoogle Scholar
• Pugh, L. R., Taylor, P. J., & Berry, K. (2015). The role of guilt in the development of post-traumatic stress disorder: A systematic review. Journal of Affective Disorders, 182, 138–150. doi:10.1016/j.jad.2015.04.026
   PubMed Web of Science ®Google Scholar
• Robinson, P. (2007). Ethics training and development in the military. Parameters, 37(1), 23.
   Google Scholar
• Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182.
   Google Scholar
• Shea, M. T., Presseau, C., Finley, S. L., Reddy, M. K., & Spofford, C. (2017). Different types of combat experiences and associated symptoms in OEF and OIF National Guard and reserve veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 9(S1), 19.
   Google Scholar
• Singer, M. (2004). Shame, guilt, self-hatred and remorse in the psychotherapy of Vietnam combat veterans who committed atrocities. American Journal of Psychotherapy, 58(4), 377.
   PubMedGoogle Scholar
• Steenkamp, M. M., Litz, B. T., Gray, M. J., Lebowitz, L., Nash, W., Conoscenti, L., … Lang, A. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18(1), 98–107.
   Google Scholar
• Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 314(5), 489–500. doi:10.1001/jama.2015.8370
   PubMed Web of Science ®Google Scholar
• Street, A. E., Gibson, L. E., & Holohan, D. R. (2005). Impact of childhood traumatic events, trauma-related guilt, and avoidant coping strategies on PTSD symptoms in female survivors of domestic violence. Journal of Traumatic Stress, 18(3), 245–252. doi:10.1002/jts.20026
   PubMed Web of Science ®Google Scholar
• Thompson, M. M., & Jetly, R. (2014). Battlefield ethics training: Integrating ethical scenarios in high-intensity military field exercises. European Journal of Psychotraumatology, 5(1), 23668. doi:10.3402/ejpt.v5.23668
   PubMed Web of Science ®Google Scholar
• Van Baarda, T. A., & Verweij, D. E. M. (Eds.). (2006). Military ethics: The Dutch approach—a practical guide. Utrecht, the Netherlands: Brill.
   Google Scholar
• Vermetten, E., & Lanius, R. A. (2012). Biological and clinical framework for posttraumatic stress disorder. Handbook of Clinical Neurology, 106, 291–342. doi:10.1016/B978-0-444-52002-9.00018-8
   PubMedGoogle Scholar
• Vermetten, E., Jetly, R., Warner, C., Bradley, P., Blanc, S. J. R., Appenzeller, G., … Kelloway, K. (2016). Moral dilemmas and mental health problems. NATO human factors in medicine. doi:10.14339/STO-TR-HFM-179. Retrieved from https://www.cso.nato.int/activity_meta.asp?act=1702.
   Google Scholar
• Walker, M. U. (2006). Moral repair: Reconstructing moral relations after wrongdoing. Cambridge University Press.
   Google Scholar
• Warner, C. H., Appenzeller, G. N., Mobbs, A., Parker, J. R., Warner, C. M., Grieger, T., & Hoge, C. W. (2011). Effectiveness of battlefield-ethics training during combat deployment: A programme assessment. The Lancet, 378(9794), 915–924. doi:10.1016/S0140-6736(11)61039-8
   PubMed Web of Science ®Google Scholar
• Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in US combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34(4), 340–347. doi:10.1002/da.22614
   Web of Science ®Google Scholar
• Worthington Jr, E. L., & Langberg, D. (2012). Religious considerations and self-forgiveness in treating complex trauma and moral injury in present and former soldiers. Journal of Psychology and Theology, 40(4), 274–288.
   Google Scholar
• Yan, G. W. (2016). The invisible wound: Moral injury and its impact on the health of Operation Enduring Freedom/Operation Iraqi Freedom veterans. Military Medicine, 181(5), 451–458. doi:10.7205/MILMED-D-15-00103
   PubMed Web of Science ®Google Scholar
• Yehuda, R., Vermetten, E., & McFarlane, A. (2012). Understanding depression as it occurs in the context of post-traumatic stress disorder. Depression Research Treatment, 2012, 178261. doi:10.1155/2012/178261
   PubMedGoogle Scholar
• Yehuda, R., & Hoge, C. W. (2016). The meaning of evidence-based treatments for veterans with posttraumatic stress disorder. JAMA Psychiatry, 73(5), 433–434. doi:10.1001/jamapsychiatry.2015.2878
   PubMed Web of Science ®Google Scholar