Civilian moral injury: associations with trauma type and high-frequency heart rate variability in two trauma-exposed community-based samples

Abstract

Background Moral injury exposure (MIE) and distress (MID) may indirectly affect the relationship between trauma exposure and alterations in autonomic regulation [assessed via high-frequency heart rate variability (hfHRV)] in civilians, but this has not been tested in prior research. We conducted two exploratory studies to examine trauma types' associations with MIE and MID among civilian medical patients (Study 1) and explore how these facets may indirectly affect the relationship between trauma type and hfHRV among civilians seeking mental health services (Study 2). Methods Participants recruited from a public hospital and/or community advertisements (Study 1, n = 72, 87.5% Black, 83.3% women; Study 2, n = 46, 71.7% Black, 97.8% women) completed measures assessing trauma type, MIE, and MID. In Study 1, trauma types that emerged as significant correlates of MIE and MID were entered into separate linear regression analyses. Trauma types identified were included as predictors in indirect effects models with MIE or MID as the mediator and resting hfHRV (assayed via electrocardiography) as the outcome. Results Childhood sexual abuse emerged as the only significant predictor of MIE, b = 0.38, p < 0.001; childhood sexual abuse, b = 0.26, p < 0.05, and adulthood sexual assault, b = 0.23, p < 0.05 were significant predictors of MID. Participants with greater MIE and MID demonstrated lower hfHRV. Adulthood sexual assault showed an indirect effect on hfHRV through MID, B = −0.10, s.e. = 0.06, 95%CI (−0.232 to −0.005). Conclusions Moral injury was uniquely associated with sexual violence and lower hfHRV in civilians. Data highlight moral injury as a pathway through which autonomic dysregulation may emerge and its salience for trauma treatment selection.

Predictors of negative moral appraisals and their association with symptoms of post‐traumatic stress and depression in the context of COVID‐19 related stressors

“…Outside the occupational context, research on trauma provides insights germane to our understanding of MI. For instance, studies have consistently shown that those who have experienced interpersonal trauma and perpetrators of violent acts (i.e., events involving actions susceptible to perceived moral violations) are more commonly associated with reactions of guilt and shame compared to other trauma types (e.g., natural disasters, motor vehicle accidents) (Badour et al., 2017; Belik et al., 2009; Lathan et al., 2022; MacNair, 2002). In addition, emerging models of trauma tend to highlight that the experience of negative moral emotions (i.e., those concerned with the preservation of social relationships) (Haidt, 2003) is likely an important maintaining mechanism in the experience of problems like PTSD, beyond the influence of non‐moral emotions (e.g., fear) which may be more amenable to traditional conditioning‐based intervention approaches (Norman et al., 2014).…”

Moral injury and substance use among United States healthcare workers

“…More research is needed to assess the role of moral injury in other externalising behaviours, including substance use. Additionally, a recent study investigating the relationship between moral injury and autonomic system dysregulation among a diverse sample of civilians suggests that PMIEs may independently contribute to stress‐related problems with autonomic regulation including heart rate variability (Lathan et al., 2022). Moreover, additional studies (Hall et al., 2022; Nieuwsma et al., 2022) describe the similarities between military and healthcare contexts, specifically noting the high‐stress circumstances and clear exposure to moral injury.…”

“…Noting that shame and anxiety of pending judgement are typically associated with moral injury, Litz et al (2009) detail three characteristics of a PMIE: (1) that it be global (i.e., not tied to any specific context(s)), (2) internal, similar to a character attribute as opposed to circumstantial, and (3) stable or ongoing. However, recent events-particularly the COVID-19 pandemic-have further highlighted that PMIEs exist in various spheres and occupations, and a detailed examination of moral injury in civilian populations is warranted (Fani et al, 2021;Koenig & Al Zaben, 2021;Lathan et al, 2022).…”