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Screening for and Treatment of Moral Injury in Veterans/Active Duty Military with PTSD

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This Research Topic in Frontiers in Psychiatry will focus on the topic of “moral injury” in the setting of post-traumatic stress disorder (PTSD) in Veterans and Active Duty Military, where psychological trauma results from combat experiences during wartime or other experiences such as rape, etc., while on ...

This Research Topic in Frontiers in Psychiatry will focus on the topic of “moral injury” in the setting of post-traumatic stress disorder (PTSD) in Veterans and Active Duty Military, where psychological trauma results from combat experiences during wartime or other experiences such as rape, etc., while on deployment to a combat theater. PTSD is one of the most common mental disorders (if not the most common and disabling disorder) suffered by Veterans and Active Duty Military personnel. PTSD in military settings, especially when it becomes chronic, is notoriously difficult to treat, with only about 20-30% of patients achieving anything close to a full remission of symptoms. PTSD is also often accompanied by extensive psychiatric comorbidity including depression, anxiety, substance abuse, and relationship problems. In addition, PTSD carries with it a significant risk of suicide in both Active Duty Military and Veterans in particular.

Moral injury (MI) is a separate syndrome that often accompanies military-related PTSD, and if not addressed, may interfere with treatment response leading to poor outcomes. The diagnosis of PTSD is based on four major fear/trauma-based symptom clusters that cause functional disability: hyperarousal/irritability, avoidance, emotional negativity/numbing, and intrusive nightmares/flashbacks. In contrast, the symptoms of MI according to trauma experts, result from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs”; “a betrayal of what’s right, by someone who holds legitimate authority, in a high-stakes situation”; or “a deep sense of transgression including feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs.” The moral dilemmas, ethical questions, and guilt caused by actions and experiences during wartime has been the subject of academic discussion since the early 1980’s, although researchers did not begin to define and study this construct until nearly 30 years later, after MI was highlighted in a seminal article published by Brett Litz and colleagues. Within the past 10 years, measures have been developed to identify MI and correlate it with PTSD symptoms and psychiatric comorbidity, and as a result, there has been increasing clinical attention paid to this syndrome.

Nevertheless, despite the frequent presence of MI in those with combat-related PTSD, it is often ignored in current psychotherapeutic treatments and remains under-researched. Treatments for moral injury in the setting of PTSD have now been developed and research is being done to assess these treatments. Few psychiatrists, however, are aware of these treatments or are familiar with measures used to identify those with MI, despite the millions of Veterans and Active Duty Military personnel that often come to them for treatment of PTSD and associated psychiatric co-morbidity (which may often be driven by MI symptoms that have not been addressed). This topic is truly at the frontier of psychiatry and deserves attention in a Research Topic that is likely to have widespread appeal (and fill a critical need in the field of psychiatry).


Keywords: Moral injury, PTSD, Veterans, Active Duty Military, Screening


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