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

Abstract

The model of posttraumatic stress disorder (PTSD) that has been dominant for many years has focused on fear conditioning and anxiety-related symptoms as main drivers of the pathology. Yet, the fear based conceptualization fails to consider the rules of modern combat, the culture of combatants, operational stressors and the moral dimension. Recently there is renewed interest in moral distress and moral injury with a focus on guilt, shame, and anger. Accumulating evidence suggests a link between transgression of moral values and symptoms of guilt and shame, anger, suicidal ideation, and PTSD in military servicemen and veterans. Although proper assessment is still in its infancy, there is a need to better understand how moral decisions can affect the mental health of military personnel at any point during their careers, including postrelease. The authors illustrate this with three clinical case reports. They conclude with a call for attention to the relation between the incurrence of moral injurious distress, and the role of guilt and shame as drivers for chronicity of PTSD. Identifying and addressing these issues can contribute to therapy adherence, facilitate successful progression, and contribute to healing and moral repair and reduce overall symptoms of PTSD.

Social Embeddedness of Firefighters, Paramedics, Specialized Nurses, Police Officers, and Military Personnel: Systematic Review in Relation to the Risk of Traumatization

“…However, excluding studies focusing on other mental health issues while only including studies on traumatization, yielded considerably fewer eligible studies (i.e., 27 military-studies, 5 firefighters studies, 1 each for police, ICU, perioperative nurses, ER-nurses, and zero for nurse anesthetist and paramedics). An explanation may be that the construct "trauma, " or even the use of the very word "trauma, " may be stigmatized (191)(192)(193)(194)(195), which may direct research away from PTSD toward other mental health problems such as substance abuse, burnout, depression, or moral injury (4,196). Some of those mental disorders have comorbidity with PTSD (7,8).…”

Killing in Combat; the Diverging Mental Health Impact on Distinct Veteran Populations – A Two-Sample Study

“…Moreover, when operating in a warzone, soldiers routinely witness the suffering and death of both the local civilian population and other injured soldiers (Fontana & Rosenheck, 1999;Tanielian et al, 2008). There is a growing body of research demonstrating how distinct warzone experiences such as acute fear, witnessing suffering, and exposure to moral transgressions may precipitate specific psychological effects in veterans (Ramage et al, 2015;Shea, Presseau, Finley, Reddy & Spofford, 2017;Vermetten & Jetly, 2018;Nordstrand et al, 2019).…”

Virtual Reality–Based Treatment for Military Members and Veterans With Combat-Related Posttraumatic Stress Disorder: Protocol for a Multimodular Motion-Assisted Memory Desensitization and Reconsolidation Randomized Controlled Trial

“…Isolated or cumulative traumatic experiences can also cause long-term psychological and spiritual struggles, including depression, anxiety, moral injury [ 5 , 16 ], and suicide [ 17 ]. Moral injury—a separate trauma syndrome that results from exposure to ethically or virtuously injurious experiences such as witnessing or participating in acts that transgress personal morals and values [ 18 ]—has been posited as a potential key comorbidity, and a compounding and complicating factor of PTSD [ 19 , 20 ].…”