Moral Injury PTSD — A Brief Discussion of the History & Treatment of Ethical Trauma
Although much is yet to be learned about the science of human morality, researchers have discovered that a perceived violation of moral tenets can result in psychological trauma (Litz et al, 2009). This psychological phenomenon is referred to as Moral Injury PTSD.
Moral injury is defined as “a particular type of trauma characterized by guilt, existential crisis, and loss of trust that may develop following a perceived moral violation” (Jinkerson 2016).
The growing study of this psychological phenomenon will lead to greater awareness of the challenges of Moral Injury PTSD. In time, it is my hope that further research will yield evidence-based pharmacological and psychotherapeutic treatments for individuals suffering from Moral Injury PTSD.
Traumatized from the Safety of a Military Bunker
The study of Moral Injury PTSD was born of PTSD research in combat veterans. The condition was formally delineated in 2009 by Brett T. Litz et al in an article highlighting the experience of a subset of veterans with PTSD whose trauma was caused by “potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”. These encounters were seen to be “deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially” (Litz et al, 2009).
In the clinical treatment of patients with PTSD, psychiatrists noted important differences in the narrative content of these soldiers’ traumatic experiences. Most of the veterans of 20th-century wars are diagnosed with PTSD because of lingering terror from a life-threatening event. However, the minority subset of veterans discussed above, although coping with similar PTSD symptoms, did not report such frightful content. Their trauma is based not on fear, but on a perceived violation of a deeply-held moral tenet.
The moral element of PTSD was further differentiated when researchers began noticing that operators of remotely piloted aircraft (RPA or drones), although faced with no threat to their personal safety, experienced a similar set of symptoms to combat-related PTSD. Research of these pilots showed that “the number of events in which RPA warfighters witnessed civilian bystanders being killed by enemy forces or felt shared responsibility for the injury or death of bystanders” were “significant predictors” of PTSD (Chapelle et al, 2019). Although RPA pilots were completely safe in military bunkers on United States soil, they struggled with the moral and ethical implications of their violent contribution to war and suffered all the hallmark symptoms of PTSD including disturbed sleep, panic attacks, suicidal and homicidal ideation, and substance abuse. They were suffering from Moral Injury PTSD.
Different Kinds of Trauma Have Different Neurological Footprints
The idea that PTSD can be subdivided based on the nature of the trauma is not unique to Moral Injury PTSD. Researchers refer to a trauma-inducing event or events as the “index trauma” (Barnes et al, 2019). Individuals can be categorized and studied based on the characteristics of their index trauma. It turns out that each kind of trauma has a different neurological footprint.
In 2015, Boccia et al “explored the possibility that different traumatic events produce different alterations in the PTSD neural network” (Boccia et al 2015). Using Positron Emission Tomography (PET) scans and functional Magnetic Resonance Imaging (fMRI) they showed that not all PTSD is the same. For example, PTSD resulting from physical and sexual abuse activated the “bilateral ACC and MCC, precuneus (pCU), superior occipital gyrus (SOG) and middle frontal gyrus”. On the other hand, combat-related PTSD “showed clusters of activation in the bilateral HC, ACC and STG…the right inferior frontal gyrus (IFG), medial and middle frontal gyrus, inferior parietal lobule (IPL) and pCU.” Although they did not study moral injury directly, these studies showed that when the index trauma was separated into the categories of combat, sexual abuse, and natural disaster, each activated different neural substrates.
In short, different types of trauma cause different neurological responses in the brain.
A fascinating study in 2019 using fMRI technology showed a difference in the resting-state brain fluctuation and functional connectivity of individuals with PTSD and in those with moral injury (Sun et al, 2019). In this study, researchers ranked the intensity of the index trauma using the Clinician-Administered PTSD Scale (CAPS) for PTSD and the Moral Injury Events Scale (MIES) for moral injury. Then they measured spontaneous fluctuations in the amplitude of low-frequency fluctuation (ALFF) and functional connectivity while the subject was in a state of rest. Their conclusion was that “neural correlates of morally injurious events and symptoms as measured specifically by MIES and its subscales may be differentiated from the neural correlates of PTSD as measured by the CAPS.” In other words, the biology of moral injury in the brain is distinctly different from that of PTSD.
One significant finding in the above study relates to the function of the left inferior parietal lobule. The researchers concluded that “morally injurious events are correlated with resting-state brain responses in the L-IPL” but that they “did not find any significant relationship between ALFF in IPL and CAPS scores”. It appears that the L-IPL is the home of morality trauma. Interestingly, other differentiating characteristics were found in neurological activity dependent on whether the trauma was related to a moral transgression performed by the self or a moral transgression performed by someone else.
Moral Injury PTSD in Veterans, Victims of Sexual Abuse, and Disillusioned Religionists
Neurological research of moral injury using brain scanning technologies such as fMRI is in its infancy and much is yet to be understood. But the progress in this field has profound implications. With its focus on the emotion of fear, PTSD can be a reductive diagnosis that does not directly address the moral component of traumatic events. The multifaceted emotional experience of combat veterans speaks to this inadequacy. Upon returning home, veterans are praised for service to their country. They may be left alone to carry not only fearful memories of battle but also the traumatic moral burden of the violent acts they performed in support of an ideology. To reduce their psychological symptoms to fear and combat-related PTSD can render the moral injury trauma untreated.
This is poignant in the experience of veterans of the Vietnam war who were met upon return with a public who objected to the ethics of the war and outspokenly criticized the politicians responsible for leading the nation into it. The trauma of reckoning with their contribution to an ethically questionable conflict can be comorbid with fear-based trauma of life-threatening combat experiences. Recognizing that moral injury is biologically different in function than fear-based PTSD will give clinicians cause for pause when diagnosing the panic attacks, flashbacks, fear, and anxiety of veterans. Further, as awareness of the neurological uniqueness of moral injury grows, perhaps psychiatric care will facilitate a more focused approach to treatment based on the characteristics of the index trauma.
Other groups will benefit from this line of research and subsequent improvements in treatment options. Victims of sexual assault who experience symptoms of PTSD not only deal with past and present fear of their abuser but also with the moral implications of their abuse. Shame may result from victim-blaming or from existing within a community that still respects the abuser and seeks to silence the victim. Victims of sexual assault may have chronic guilt that they did not defend themselves adequately or because they experienced sexual arousal during the abuse. The guilt and shame of these moral injuries must be treated with precision so that victims can move forward and reconstruct a world view based on a new set of post-abuse moral principles.
Similarly, sufferers of spiritual trauma within high demand or cult-like religious groups may face guilt and shame commingled with fear upon disillusionment (McPhillips, 2018). With symptoms similar to complex-PTSD, Religious Trauma Syndrome (RTS) may include aspects of Moral Injury PTSD when disillusioned members become aware of their complicity in ethically questionable religious practices.
As science continues to study Moral Injury PTSD, treatments can be tailored to the characteristics of this condition. Perhaps medications will be developed to target brain locations associated with moral injury index traumas, such as the left inferior parietal lobule. Psychotherapists can leverage their understanding of Moral Injury PTSD to develop therapeutic approaches that target the moral aspects of trauma.
Sun et al state, “knowledge of relevant targets could help predict, guide selection, or monitor treatment response of psychotherapy, pharmacotherapy, or brain stimulation, which may be optimally suited for individual patients” (Sun et al, 2019). With 3.5% of the US population suffering from PTSD, many stand to benefit from improvements in our understanding of Moral Injury PTSD.
References:
Barnes, Haleigh A., Hurley, Robin A., Taber, Katherine H. (2019) Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different. The Journal of Neuropsychiatry and Clinical Neurosciences 2019 31:2, A4–103
Boccia, M., D’Amico, S., Bianchini, F., Marano, A., Giannini, A., Piccardi, L., & Giannini, A. M. (2016). Different neural modifications underpin PTSD after different traumatic events: an fMRI meta-analytic study. Brain Imaging & Behavior, 10(1), 226–237. https://doi-org.ezproxy.umgc.edu/10.1007/s11682-015-9387-3
Chappelle, W., Goodman, T., Reardon, L., & Prince, L. (2019). Combat and operational risk factors for post-traumatic stress disorder symptom criteria among United States air force remotely piloted aircraft “Drone” warfighters. Journal of Anxiety Disorders, 62, 86–93. https://doi-org.ezproxy.umgc.edu/10.1016/j.janxdis.2019.01.003
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069
Litz, Brett T., Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, Shira Maguen, Moral injury and moral repair in war veterans: A preliminary model and intervention strategy, Clinical Psychology Review, Volume 29, Issue 8, 2009, Pages 695–706, ISSN 0272–7358, https://doi.org/10.1016/j.cpr.2009.07.003.
McPhillips, K. (2018). “Soul Murder”: Investigating Spiritual Trauma at the Royal Commission. Journal of Australian Studies, 42(2), 231–242. https://doi.org.ezproxy.umgc.edu/10.1080/14443058.2029
Reisman M. (2016). PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next. P & T: a peer-reviewed journal for formulary management, 41(10), 623–634.
