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

Abstract

ABSTRACTThe 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.