Literature describing the phenomenology of the stress of combat suggests that war-zone experiences may lead to adverse psychological outcomes such as post-traumatic stress disorder not only because they expose persons to life threat and loss but also because they may contradict deeply held moral and ethical beliefs and expectations. We sought to develop and validate a measure of potentially morally injurious events as a necessary step toward studying moral injury as a possible adverse consequence of combat. We administered an 11-item, self-report Moral Injury Events Scale to active duty Marines 1 week and 3 months following war-zone deployment. Two items were eliminated because of low item-total correlations. The remaining 9 items were subjected to an exploratory factor analysis, which revealed two latent factors that we labeled perceived transgressions and perceived betrayals; these were confirmed via confirmatory factor analysis on an independent sample. The overall Moral Injury Events Scale and its two subscales had favorable internal validity, and comparisons between the 1-week and 3-month data suggested good temporal stability. Initial discriminant and concurrent validity were also established. Future research directions were discussed.

BackgroundAcute coronary syndromes (ACS; myocardial infarction or unstable angina) can induce posttraumatic stress disorder (PTSD), and ACS-induced PTSD may increase patients’ risk for subsequent cardiac events and mortality. Objective: To determine the prevalence of PTSD induced by ACS and to quantify the association between ACS-induced PTSD and adverse clinical outcomes using systematic review and meta-analysis. Data Sources: Articles were identified by searching Ovid MEDLINE, PsycINFO, and Scopus, and through manual search of reference lists.Methodology/Principal FindingsObservational cohort studies that assessed PTSD with specific reference to an ACS event at least 1 month prior. We extracted estimates of the prevalence of ACS-induced PTSD and associations with clinical outcomes, as well as study characteristics. We identified 56 potentially relevant articles, 24 of which met our criteria (N = 2383). Meta-analysis yielded an aggregated prevalence estimate of 12% (95% confidence interval [CI], 9%–16%) for clinically significant symptoms of ACS-induced PTSD in a random effects model. Individual study prevalence estimates varied widely (0%–32%), with significant heterogeneity in estimates explained by the use of a screening instrument (prevalence estimate was 16% [95% CI, 13%–20%] in 16 studies) vs a clinical diagnostic interview (prevalence estimate was 4% [95% CI, 3%–5%] in 8 studies). The aggregated point estimate for the magnitude of the relationship between ACS-induced PTSD and clinical outcomes (ie, mortality and/or ACS recurrence) across the 3 studies that met our criteria (N = 609) suggested a doubling of risk (risk ratio, 2.00; 95% CI, 1.69–2.37) in ACS patients with clinically significant PTSD symptoms relative to patients without PTSD symptoms.Conclusions/SignificanceThis meta-analysis suggests that clinically significant PTSD symptoms induced by ACS are moderately prevalent and are associated with increased risk for recurrent cardiac events and mortality. Further tests of the association of ACS-induced PTSD and clinical outcomes are needed.

A common assumption among clinicians and researchers is that war trauma primarily involves fear-based reactions to life-threatening situations. However, the authors believe that there are multiple types of trauma in the military context, each with unique perievent and postevent response patterns. To test this hypothesis, they reviewed structured clinical interviews of 122 active duty service members and assigned the reported index (principal, most currently distressing) events to one or more of the following categories: Life Threat to Self, Life Threat to Others, Aftermath of Violence, Traumatic Loss, Moral Injury by Self, and Moral Injury by Others. They found high interrater reliability for the coding scheme and support for the construct validity of the categorizations. In addition, they discovered that certain categories were related to psychiatric symptoms (e.g., reexperiencing of the traumatic event, guilt, anger) and negative thoughts about the world. Their study provides tentative support for use of these event categories.

We demonstrate the utility of partitioning the spiritual well-being (SpWB) construct into spiritual and religious components using results from a study of the relationship of existential well-being to health-related quality of life (HRQOL) in a sample of 237 cancer survivors. Existential and religious well-being were measured using the FACIT-Sp-12 and HRQOL was measured using the mental and physical component scores of the SF-12. In hierarchical linear regression analyses, existential well-being fully mediated religious well-being's effect on HRQOL and explained unique variance in both the mental and physical HRQOL domains, controlling for demographic, disease, and psychosocial variables previously shown to impact HRQOL. Religious well-being was not predictive of HRQOL.

Katrina-related trauma and its psychological sequelae will remain a significant public health issue for years to come. The identification of several vulnerability factors related to ASD and PTSD provides a brief sketch of those at greatest risk.

The cognitive perspective on post-traumatic stress disorder (PTSD) has been successful in explaining many PTSD-related phenomena and in developing effective treatments, yet some of its basic assumptions remain surprisingly under-examined. The present study tested two of these assumptions: (1) situational appraisals of the event as violating global meaning (i.e., beliefs and goals) is related to PTSD symptomatology, and (2) the effect of situational appraisals of violation on PTSD symptomatology is mediated by global meaning (i.e., views of self and world). We tested these assumptions in a cross-sectional study of 130 college students who had experienced a DSM-IV level trauma. Structural equation modeling showed that appraisals of the extent to which the trauma violated one’s beliefs and goals related fairly strongly to PTSD. In addition, the effects of appraisals of belief and goal violations on PTSD symptoms were fully mediated through negative global beliefs about both the self and the world. These findings support the cognitive worldview perspective, highlighting the importance of the meaning individuals assign to traumatic events, particularly the role of meaning violation.

The fundamental assertion of worldview-based models of posttraumatic stress disorder is that trauma symptoms result when traumatic experiences cannot be readily assimilated into previously held worldviews. In two studies, we test the anxiety buffer disruption hypothesis, which states that trauma symptoms result from the disruption of normal death anxiety-buffering functions of worldview. In Study 1, participants with trauma symptoms greater than the cutoff for PTSD evinced greater death-thought accessibility than those with sub-clinical or negligible symptoms after a reminder of death. In Study 2, participants with clinically significant trauma symptoms showed no evidence of worldview defense though death-thoughts were accessible. These results support the anxiety buffer disruption hypothesis, and suggest an entirely new approach to experimental PTSD research.

Acute stress disorder (ASD) is a poorly understood and controversial diagnosis (Harvey & Bryant, 2002). The present study used confirmatory factor analysis (CFA) to test the factor structure of the most widely used self-report measure of ASD, the Acute Stress Disorder Scale, in a sample of Hurricane Katrina evacuees relocated to a Red Cross emergency shelter in Austin, Texas. Results indicated that the proposed four-factor structure did not fit the data well. However, an alternate 2-factor model did fit the data well. This model included a second-order Distress factor (onto which the Reexperiencing, Arousal, and Avoidance factors loaded strongly) that was positively correlated with the Dissociation factor. Implications for the ASD construct and its measurement are discussed. Keywordsacute stress disorder; factor structure; natural disaster; Hurricane Katrina; trauma Acute stress disorder (ASD) is a poorly understood and controversial diagnosis (Harvey & Bryant, 2002). The nature, uniqueness, utility, and symptom structure of the disorder have been called into question, and changes to its diagnostic criteria (in particular, deemphasizing the role of dissociation; Bryant, 2007) are being considered for DSM-V. Some have even called for ASD to be deleted from DSM-V altogether (e.g., Spitzer, First, & Wakefield, 2007). However, very little empirical research has rigorously assessed ASD symptoms, and none have subjected the theoretical symptom structure to statistical model testing. In the present study, we examine the factor structure of ASD symptoms in a sample of individuals who were temporarily residing in a Red Cross shelter in Austin, TX, having fled their homes in the aftermath of Hurricane Katrina. This Category 3 hurricane, which made landfall in southeast Louisiana on August 29, 2005, was one of the deadliest in US history. While Katrina left a trail of destruction along the Gulf coast from central Florida to Texas, the greatest damage and loss of life occurred inNew Orleans, Louisiana, which flooded following catastrophic levee failures. In the weeks following the disaster, thousands of evacuees were temporarily housed in over 470 Red Cross operated shelters and evacuation centers across the nation (see Brodie, Weltzien,