Exploring the association between moral injury and posttraumatic stress symptoms among Canadian public safety personnel.

LAY SUMMARYBoth moral injury (MI) and posttraumatic stress disorder (PTSD) can result from adverse experiences (potentially morally injurious events [PMIEs] for the former and Criterion A events for the latter) and may lead to similar symptoms. Thus, debate is ongoing as to whether MI and PTSD are distinct. Depressive symptoms can also follow these events and may also overlap with symptoms of MI and PTSD. This study investigated how distinct MI is from PTSD and depression by examining networks composed of MI-related outcomes (trust violation, shame, functioning), PTSD symptom clusters, and depression for participants who reported experiencing a PMIE and those who did not. This study is the first of its kind to use MI outcomes with PTSD and depression in a network analysis. The results suggest that MI, PTSD, and depression are distinct but related phenomena, with more connections between these phenomena present particularly among those who experienced a PMIE. Moreover, the negative alterations in cognition and mood cluster of PTSD and MI-related functioning appears to explain some of the co-occurrence among constructs.

BackgroundCanadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms.ObjectiveThis study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan.MethodsWe employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns.ResultsClients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance.ConclusionsTailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation.Trial RegistrationClinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032

Aim: Moral injury (MI), originally studied in military contexts, refers to emotional distress resulting from actions that conflict with one's core values. MI outcomes may help explain how potentially morally injurious events (PMIEs) contribute to mental health issues, yet empirical evidence remains limited. This longitudinal study examined whether MI outcomes mediate the relationship between PMIE exposure during combat and posttraumatic stress symptom (PTSS) clusters following discharge. Method: We followed 374 male combat veterans over a five-year period. Pre-enlistment psychological characteristics were conducted 12 months prior to enlistment (T1). PMIE exposure was measured during the final month of military service (T2) using the Moral Injury Events Scale (MIES), capturing experiences throughout active duty. MI outcomes were assessed six months post-discharge (T3) using the Expressions of Moral Injury Scale–Military Version–Short Form (EMIS-M-SF). Finally, PTSS clusters were evaluated one year after discharge (T4) using the PTSD Checklist for DSM-5 (PCL-5). Results: A total of 48.7% of participants reported exposure to PMIEs, while 8% met criteria for probable PTSD. Path analysis demonstrated a direct effect of PMIE-betrayal (T2) on arousal and reactivity as well as negative alterations in cognition and mood symptom clusters (T4). Results also showed indirect associations between exposure to all PMIE dimensions (T2) and PTSS clusters (T4) via MI outcomes (T3). Conclusions: Findings underscore the role of MI outcomes in the development of specific PTSS clusters following PMIE exposure. Integrating MI-informed interventions may enhance treatment for veterans transitioning to civilian life.

The Psychiatric Ramifications of Moral Injury Among Veterans

Background: Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military populations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse). Objective: To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression. Method: We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts. Results: We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide. Conclusions: These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.

Characteristics and Prevalence of Posttraumatic Stress Disorder and Posttraumatic Stress Symptoms Among Adults with Hemophilia a and B

Many women with posttraumatic stress disorder (PTSD) after child sexual abuse (CSA) suffer from sexual problems. However, little is known about the frequency of female sexual dysfunctions (FSD) as defined by DSM-5 among women with PTSD due to CSA. Furthermore, factors related to FSD in this patient population are understudied. To assess prevalence rates and clinical correlates of FSD according to DSM-5 criteria in women with PTSD after CSA, a structured clinical interview for sexual dysfunctions according to DSM-5 criteria was administered in a sample of 137 women with PTSD after CSA. Participants also completed measures for PTSD, depression symptoms, and borderline personality disorder symptoms. The association between FSD, severity of abuse, PTSD-, depression-, borderline symptom severity, and age was examined. In a second step, the association between FSD and PTSD-clusters was assessed. Diagnostic criteria of female sexual interest/arousal disorder (FSIAD) were met by 2.6% of women in our sample. 5.2% met criteria of female orgasmic disorder (FOD), and 11.8% those of genito-pelvic pain/penetration disorder (GPPPD). PTSD symptom severity predicted number of fulfilled criteria of FSIAD and FOD, the cluster “negative alterations in cognition and mood,” was associated with more fulfilled criteria in FSIAD and FOD. The majority of women reported sexual problems, but diagnostic criteria of FSD were met by only a small number of participants. PTSD symptoms, especially the cluster “negative alterations in cognition and mood,” seem to be related to female sexual functioning after CSA.

Objectives/Goals: Mood and anxiety disorders are a risk factor (Ozer et al., 2003) for posttraumatic stress disorder (PTSD) following trauma exposure. As such, a latent internalizing dimension may also be a risk factor. We examine how the shared variance between mood and anxiety symptoms (as in HiTOP; Kotov et al., 2021) impacts development of posttraumatic stress (PTS) symptoms, and symptom clusters. Methods/Study Population: Using data from a prior study of individuals who arrived at emergency rooms and were assessed at later time points (AURORA study; McLean et al., 2020), our sample included 1866 participants (1208 females, Mage = 38.49 years) with available data for the proposed analyses. A latent factor (INTtotal) was operationalized as the shared variance between mood and anxiety symptoms (PROMIS Anxiety and Depression; Cella et al., 2010) as well as PTS symptoms (PCL-5, Weathers et al., 2013). We computed a second internalizing factor excluding PTS symptoms (INTma) to isolate the contribution of baseline affect and anxiety from PTS at baseline. We examined how baseline PTS symptoms, INTtotal, and INTma compare as prospective predictors for PTS symptoms at later time points and how these variables predict individual PTS symptoms. Results/Anticipated Results: Baseline INTma, INTtotal, and PTS symptoms were significant prospective predictors of PTS symptoms across all time points (all with t > 10, p < .005). When focusing on INTma relative to DSM-5 PTSD criterion (American Psychiatric Association, 2013), INTma significantly predicted later symptoms at six months posttrauma pertaining to Criterion D (t = 18.88, p < .005), negative alterations in cognition and mood, Criterion E (t = 15.44, p < .005) arousal and reactivity, and Criterion B, intrusion (t = 15.44, p < .005). INTma significantly predicted symptoms in Criterion C, avoidance, though to a lesser degree (t = 12.87, p Discussion/Significance of Impact: These findings bolster the utility of examining PTSD risk factors through a transdiagnostic lens. INTma was predictive of later PTS symptoms, independent of baseline PTS. Our analyses reveal clinical implications for the assessment of PTSD, and the tailoring of treatment for patients high in internalizing following trauma exposure.

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Post-traumatic stress disorder (PTSD) is a severe psychiatric illness that disproportionately affects military personnel, veterans, and public safety personnel (PSP). Evidence demonstrates that PTSD is significantly associated with difficulties with emotion regulation (ER) and difficulties with cognitive functioning, including difficulties with attention, working memory, and executive functioning. A wide body of evidence suggests a dynamic interplay among cognitive dysfunction, difficulties with ER, and symptoms of PTSD, where numerous studies have identified overlapping patterns of alterations in activation among neuroanatomical regions and neural circuitry. Little work has examined interventions that may target these symptoms collectively. The primary objective of this pilot randomized controlled trial (RCT) with a parallel experimental design was to assess the effectiveness of goal management training (GMT), a cognitive remediation intervention, in reducing difficulties with cognitive functioning, and to determine its effects on PTSD symptoms and symptoms associated with PTSD, including difficulties with ER, dissociation, and functioning among military personnel, veterans, and PSP. Forty-two military personnel, veterans, and PSP between the ages of 18 and 70 with symptoms of PTSD were recruited across Ontario, Canada between October 2017 and August 2019. Participants were randomized to either the waitlist (WL) (n = 18) or the GMT (n = 22) condition. Participants in both conditions received self-report measures and a comprehensive neuropsychological assessment at baseline, post-intervention, and 3-month follow-up. Following their completion of the 3-month follow-up, participants in the WL condition were given the opportunity to participate in GMT. Assessors and participants were blind to intervention allocation during the initial assessment. A series of 2 (time) × 2 (group) ANOVAs were conducted to assess the differences between the WL and GMT conditions from pre- to post-intervention for the self-report and neuropsychological measures. The results demonstrated significant improvements in measures of executive functioning (e.g., verbal fluency, planning, impulsivity, cognitive shifting, and discrimination of targets) and trending improvements in short-term declarative memory for participants in the GMT condition. Participants in the GMT condition also demonstrated significant improvements from pre- to post-testing in measures of subjective cognition, functioning, PTSD symptom severity, difficulties with ER, dissociative symptom severity, and depression and anxiety symptoms. No adverse effects were reported as a result of participating in GMT. The results of this pilot RCT show promise that GMT may be a useful intervention to improve symptoms of cognitive dysfunction, symptoms of PTSD, and symptoms associated with PTSD within military personnel, veterans, and PSP. Future work is needed to address the small sample size and the durability of these findings.

Transcranial direct current stimulation (tDCS) for post-traumatic stress disorder (PTSD): A randomized, double-blinded, controlled trial

Toward the Predeployment Detection of Risk for PTSD

War zone veterans who experience posttraumatic stress disorder (PTSD) symptoms might struggle with co-occurring cognitive, emotional, and behavioral expressions of suffering that align with conceptual definitions of moral injury (MI). However, given that PTSD is a multidimensional condition, disentangling the apparent interplay with MI may inform clinical practice and research. This study incorporated a cross-lagged design to explore temporal associations between self- and other-directed outcomes related to MI and severity of DSM-5 PTSD symptom clusters while accounting for depressive symptoms. Drawing on the Expressions of Moral Injury Scale-Military Version in a community sample of 182 previously deployed veterans, MI-related outcomes were linked with severity of PTSD symptom clusters at two assessments spaced apart by 6 months, rs = .58-.62. Of possible models for conceptualizing the temporal nature of these associations, structural equation modeling analyses revealed a cross-lagged primary MI model best fit veterans' responses. Within this model, veterans' self-directed MI at Time 1 predicted greater PTSD symptoms at the 6-month follow-up. However, an equivalent cross-lagged path also emerged between Time 1 PTSD Cluster D symptoms and self-directed MI at Time 2, suggesting the value of a reciprocal MI model for this symptom domain. In contrast, other-directed outcomes of MI were not linked with PTSD in the presence of other variables. Overall, these findings support the prognostic value of assessing for MI-related outcomes among veterans who might be struggling with PTSD symptomatology, particularly with respect to self-directed problems associated with enduring moral distress.

4286 The Relationship Between Tinnitus-Related Distress and PTSD Symptoms Among Post 9/11 Veterans with Posttraumatic Headache

Background: Given the highly stressful environment surrounding the SARS-CoV-2 pandemic, healthcare workers (HCW) and public safety personnel (PSP) are at an elevated risk for adverse psychological outcomes, including posttraumatic stress disorder (PTSD) and alcohol/substance use problems. As such, the study aimed to identify associations between PTSD severity, related dissociation and emotion dysregulation symptoms, and alcohol/substance use problems among HCWs and PSP. Methods: A subset of data (N = 498; HCWs = 299; PSP = 199) was extracted from a larger study examining psychological variables among Canadian HCWs and PSP during the pandemic. Structural equation modelling assessed associations between PTSD symptoms and alcohol/substance use-related problems with dissociation and emotion dysregulation as mediators. Results: Among HCWs, dissociation fully mediated the relation between PTSD and alcohol-related problems (indirect effect β = .133, p = .03) and emotion dysregulation partially mediated the relation between PTSD and substance-related problems (indirect effect β = .151, p = .046). In PSP, emotion dysregulation fully mediated the relation between PTSD and alcohol-related problems (indirect effects β = .184, p = .005). For substance-related problems among PSP, neither emotion dysregulation nor dissociation (ps >.05) had any effects. Conclusion: To our knowledge, this is the first study examining associations between PTSD severity and alcohol/substance use-related problems via mediating impacts of emotion dysregulation and dissociation among HCWs and PSP during the SARS-CoV-2 pandemic. These findings highlight dissociation and emotion dysregulation as important therapeutic targets for structured interventions aimed at reducing the burden of PTSD and/or SUD among Canadian HCWs or PSP suffering from the adverse mental health impacts of the SARS-CoV-2 pandemic.