Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women

Guilt is conceptualized as a multidimensional construct consisting of negative affect and a set of interrelated cognitions. Guilt magnitude is thought to be a function of the magnitudes of six variables posited as primary components of guilt: a negative event, distress, perceptions of responsibility, lack of justification, wrongdoing, and false beliefs about preoutcome knowledge. The model was tested with samples of Vietnam veterans and battered women. Participants rated their reactions to and perceived roles in trauma-related events. Among Vietnam veterans, distress ratings were highly correlated with guilt severity. Cognitive guilt-component variables were significantly correlated with guilt in both groups. In multiple regression, guilt components accounted for 61% of variance in veterans' guilt and 44% of variance in women's guilt. Among veterans, distress ratings were highly correlated with measures of PTSD and depression. In both groups, cognitive guilt-component variables were positively correlated with psychopathology. Results support the view that beliefs about one's role in trauma are important factors in posttrauma adjustment.     

Recontextualising moral injury among military veterans: An integrative theoretical review

Moral injury was originally conceived as a socially-inflicted wound of betrayal experienced by military veterans (Shay, 1994). However, moral injury has since been redefined by psychological researchers as an individualised, predominantly perpetration-driven, and psychopathological phenomenon (e.g., Currier et al., 2015; Jinkerson, 2016). However, social scientific researchers (e.g., Hodgson & Carey, 2017; Molendijk, 2019; Wiinikka-Lydon, 2017) have contested mainstream psychology's medicalisation and decontextualisation of moral injury. This theoretical review integrates insights from across these discourses, and brings them into dialogue with ideas from moral psychology, evolutionary science, and community psychology. The aim of this cross-disciplinary review is to promote a more holistic understanding of moral injury that does justice to its individual and social dimensions. Drawing on these different theoretical strands, this paper proposes that moral injury can be best understood as a psychological wound to basic human needs for social belonging and cohesion. The implications of this integrative understanding of moral injury for applied psychologists and other societal actors are explored. While the relevance of moral injury to civilian populations such as health and social care professionals is clear (e.g., Dombo et al., 2013; French et al., 2021), this paper focuses on military veterans, whose experiences originally prompted the coinage of the term. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.     

The structure of DSM-5 posttraumatic stress disorder symptoms in war veterans

Background and Objectives: The present research examined the underlying factor structure of posttraumatic stress disorder (PTSD) as conceptualized in the recently published fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5). Design: Participants were 258 trauma-exposed Iraq/Afghanistan war veterans. Methods: A self-report measure of PTSD symptoms was administered to all participants and confirmatory factor analysis (CFA) was used to compare several different models of PTSD. Results: CFA revealed that the best-fitting model was a six-factor model in which symptoms loaded onto the factors of intrusion, avoidance, negative affect, anhedonia, dysphoric arousal, and anxious arousal. Conclusions: These findings have important implications for ongoing conceptualization of PTSD and suggest that additional modifications to the diagnostic criteria for PTSD may still be warranted to more accurately reflect the underlying structure of PTSD symptoms.     

Posttraumatic Stress,Posttraumatic Growth,and Satisfaction With Life in Military Veterans

Objective: Military veterans are more likely than civilians to experience trauma and posttraumatic stress disorder (PTSD). Research suggests, however, that some people who experience trauma, including veterans, report posttraumatic growth (PTG), or positive personal changes following adversity. In this study, we tested a comprehensive model of PTG, PTSD, and satisfaction with life in a veteran population, exploring the roles of challenges to core beliefs, types of rumination, sex, and time since event. Method: Data were collected via Amazon’s Mechanical Turk, an online crowdsourcing website, from veterans (N = 197) who had experienced a stressful event within the last 3 years (M = 16.66 months, SD = 12.27 months). Structural equation modeling was used to test an integrated conceptual model of PTG, PTSD, and satisfaction with life. Results: Results showed that challenge to core beliefs was directly associated with both deliberate and intrusive rumination. Deliberate rumination was positively related to PTG; intrusive rumination was positively related to symptoms of PTSD. PTG and PTSD, in turn, mediated the relationship between rumination styles and satisfaction with life; PTG was related to higher satisfaction with life; and PTSD was negatively related to satisfaction with life. Results failed to show differences on any model variables as a function of time since event or sex. Conclusion: Results indicate that the intentional facilitation of PTG may be a complementary and alternative option to the reduction of PTSD symptoms for improving satisfaction with life. Findings suggest that efforts to facilitate PTG should be focused on strategies for promoting deliberate rumination.     

Improving Mental Health Treatment Utilization in Military Veterans: Examining the Effects of Perceived Need for Care and Social Support

Many veterans with mental health problems do not adequately utilize needed care. Research has focused on identifying barriers to mental health care in veterans. The current study adds to existing literature by examining whether perceived need for treatment and social support affect treatment utilization in a national longitudinal survey of Iraq and Afghanistan veterans (n = 1,090). The Health Beliefs Model (HBM) postulates that a key reason why patients fail to obtain needed care is their belief “it’s up to me to handle my own problems.” This view was endorsed by 42% in the current national sample of veterans and was found in multivariate analysis to predict less treatment seeking in the next year. Mediation analysis revealed that veterans with higher ratings of social support were less likely to believe they needed to solve mental health problems on their own, indirectly equating to higher odds of treatment use. Simultaneously, findings indicated that posttraumatic stress disorder (PTSD) had a direct effect on more mental health visits but was also associated with higher endorsement that one needed to handle one’s own problems and thus had an indirect effect of reducing mental health visits. Both social support and PTSD affected veterans’ perceptions of needing to solve one’s own problems, significantly predicted follow-up with mental health care. As a result, the findings indicate that clinicians’ should explore veterans’ belief systems about perceived treatment need as well as investigate the role of social support to improve mental health treatment utilization.     

Latent classes of posttraumatic stress and growth

Background and Objectives: Potentially traumatic events may lead to different patterns of posttraumatic stress symptoms and posttraumatic growth. The objective of the present study was to identify subgroups with different patterns of posttraumatic reactions, and to determine whether these subgroups differed in terms of personal and social resources and indicators of adjustment. Design: This study used survey data collected 10 months after the 2011 Oslo bombing attack to investigate patterns of reactions among ministerial employees (N = 1970). Methods: We applied latent class analyses with covariates to extract subgroups of individuals. Results: Three classes of individual reactions were extracted, and these were similar among those who were and those who were not physically proximate to the bombing attack: “High stress/high growth” (27% and 11%, respectively), “Low stress/high growth” (74% and 42%, respectively), and “Low stress/low growth” (only among the not physically proximate: 47%). The classes differed in terms of gender, neuroticism, and social support as well as life satisfaction and daily functioning. Conclusions: Heterogeneous patterns of posttraumatic reactions were found. Physical proximity is not necessary to experience posttraumatic stress or growth after political violence. Among individuals with low stress, posttraumatic growth may not encompass higher life satisfaction or functioning.     

Physiological arousal and attention in veterans with posttraumatic stress disorder

Psychophysiological reactivity has been well documented in WWII, Korean Conflict, and Vietnam veterans with posttraumatic stress disorder (PTSD). In addition, these individuals have demonstrated cognitive impairments within the domains of attention, concentration, new learning, and memory. However, there has been no research examining the impact of physiological arousal on attention in individuals with PTSD. This study documents the level of physiological arousal and associated disruption of attentional abilities in 28 Persian Gulf War veterans (18 without PTSD or other psychopathology and 10 with PTSD). This population represents a group of combat trauma victims who experienced a relatively acute onset of PTSD, thus providing a unique opportunity to compare prior psychophysiological and cognitive results with a group of veterans who manifested a recent onset of PTSD. Results indicated relatively comparable psychophysiological reactivity and arousal between Persian Gulf War veterans with PTSD and Persian Gulf War veterans without PTSD. Furthermore, attentional processes of veterans with PTSD were not more disrupted than in comparison soldiers. Results suggest that the intensity and chronicity of the disorder may impact physiological arousal and disruption of cognitive functioning. Following Persian Gulf War veterans with PTSD over time may reveal that psychophysiological arousal becomes more pronounced with chronicity, perhaps as memory networks become strengthened and/or neuroendocrine systems become increasingly disrupted.     

Social Support and Postdeployment Coping Self-Efficacy as Predictors of Distress Among Combat Veterans

This study evaluated the indirect effect of received social support on distress severity (i.e., posttraumatic stress and depression symptom severity) among 89 combat veterans. Through integrating the social support deterioration deterrence model and the enabling hypothesis, mediating roles of perceived social support and self-efficacy specific to postdeployment adaptation were investigated. Results showed that (a) received social support and perceived social support were not related, and (b) both received and perceived social support indirectly predicted distress severity (posttraumatic stress and depression symptom severity) through postdeployment coping self-efficacy. Specifically, high received and perceived social support independently predicted high postdeployment coping self-efficacy, and high postdeployment coping self-efficacy predicted lower distress severity levels. Theory enhancement and future research needs are discussed.     

The Effectiveness of Emotionally Focused Couples Therapy With Veterans With PTSD: A Pilot Study

The current study is a pilot project conducted at Baltimore VA Medical Center investigating the use of emotionally focused couples therapy (EFT) for couples in which one partner is a veteran who has been diagnosed with posttraumatic stress disorder (PTSD). Fifteen couples enrolled in the study and seven of these couples completed treatment (26 to 36 weekly sessions of EFT). Both partners were assessed on measures of relationship satisfaction, psychological distress, depression, and quality of life, and veterans were assessed on measures of PTSD symptoms at baseline and 2 weeks after the intervention. Paired t-tests were used to compare scores before and after EFT. In terms of results, the veterans' partners reported significant improvements in relationship and life satisfaction and in decreased depression and a decrease in psychological distress. Veterans demonstrated a significant decrease in self-reported symptoms of PTSD. These results provide preliminary evidence for the usefulness of EFT to help foster improved relationship satisfaction, and psychological well-being for veterans with PTSD and their partners who completed treatment.     

Frequency and impact of trauma in older women: A military and nonmilitary sample

Understanding the impact of trauma on late-life functioning in older females is needed in order to provide best care. We explored the impact of trauma on late-life psychological and physical health and functioning among older women (n = 48) who served in the military, or participated in a military lifestyle. Eleven of these women were not veterans, but married to military personnel. Number of traumatic exposures and types of events experienced was associated with increased trauma symptom severity. Trauma symptom severity was associated with decreased physical functioning and increased pain. Increased numbing and avoidance was significantly associated with poorer physical functioning and increased pain. Older women in this study remained at risk of experiencing negative consequences of trauma in terms of increased quantity and severity of trauma symptoms and physical decline and pain. Clinical and research implications are discussed.     

Emotion Dysregulation in Comorbid Posttraumatic Stress Disorder and Substance Use Disorders: A Narrative Review

Co-occurrence of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) is extremely common and is associated with elevated dropout and relapse rates. Given that PTSD/SUD co-occurrence rates among veterans have been found to be as high as 55?75%, it is important to identify mechanisms that may affect the interplay of both disorders. Emotion dysregulation (ED) presents a candidate mechanism that may underlie poor treatment response in co-occurring PTSD/SUD. This article proposes a transdiagnostic emotion regulation framework that considers ED conceptualized as a combination of low ability to tolerate emotional distress (low distress tolerance) and difficulties in the goal-directed use of emotion regulation strategies as a key risk factor in co-occurring PTSD/SUD. The authors review empirical findings from self-report and laboratory-based studies of ED in PTSD. They describe psychological explanations of the emotion-substance relationship and review studies documenting ED in SUDs and in co-occurring PTSD/SUD. The literature on ED in PTSD/SUD suggests that (a) patients with PTSD may resort to substances to cope with trauma-related symptoms due to ED, and (b) ED may maintain SUD symptoms and interfere with psychological treatment. Longitudinal studies on bidirectional relationships between ED and substance use in PTSD are needed, particularly research examining the course of ED in PTSD patients who use substances versus those who do not.     

The Causes,Course, and Consequences of Anger Problems in Veterans Returning to Civilian Life

While anger is a common problem for veterans returning from wars in Afghanistan and Iraq, veterans' understanding of the causes, course, and consequences of anger has not been explored. We conducted this qualitative study to learn veterans' perspectives about their anger problems. We identify and describe three distinct patterns of anger problems that emerged as a consequence of (a) loss of structure during reintegration to civilian life, (b) moral injury sustained through a wartime experience, and (c) posttraumatic stress disorder (PTSD). While anger problems tended to be short lived for those experiencing loss of structure, problems persisted for years for those with moral injury or PTSD. Anger following all three patterns negatively impacted veterans' experiences with reintegration. We discuss the implications of these findings.     

Virtual Reality and Cognitive-Behavioral Therapy for Driving Anxiety and Aggression in Veterans: A Pilot Study

Within the U.S. military, motor vehicle accidents (MVAs) are the leading cause of preventable morbidity and mortality. Prior combat exposure and anxiety symptoms are associated with risky and aggressive driving, which is responsible for over half of MVA fatalities. Therefore, interventions are needed to reduce driving anxiety and aggression in veterans in order to mitigate the public health impact of MVAs. Virtual reality exposure therapy (VRET) offers safe, controlled exposure to distressing stimuli. The current study piloted a novel virtual reality and cognitive behavioral intervention (VRET + CBT) for veterans that integrated both anxiety and anger management components. Virtual reality driving scenarios were delivered in a driving simulator and tailored for the military population. Six previously deployed veterans completed eight intervention sessions, as well as pre/post, one month follow-up and six to nine month follow-up assessments. Repeated measures ANOVAs demonstrated significant decline and large effect sizes for PTSD symptoms, driving phobia, hyperarousal in driving situations, anxiety/anger-related thoughts and behaviors, and risky driving. Hyperarousal in driving situations declined by 69%, aggressive driving declined by 29%, and risky driving declined by 21%. Treatment gains were maintained at follow-up. Recruitment, retention, immersion, simulator sickness scores, and qualitative feedback demonstrated feasibility of the intervention. Implications for future research and adaptation are discussed.     

Anhedonia and emotional numbing in combat veterans with PTSD

We explored relationships between anhedonia and posttraumatic stress disorder (PTSD) symptom clusters, including their role in predicting psychiatric comorbidity. Our measure of anhedonia was derived from an examination of the latent structure of the Beck Depression Inventory. We found evidence for a two-factor solution, leading to anhedonia and undifferentiated, global depressive symptoms scales. In primary analyses, anhedonia had a unique positive relationship with PTSD's emotional numbing symptoms and minimal relationships with other PTSD symptoms. Upon examining the incremental validity of appetitive functioning (i.e., anhedonia, emotional numbing) over and above aversive functioning (i.e., re-experiencing, avoidance, and hyper-arousal PTSD symptoms) variables, greater emotional numbing increased the likelihood of being diagnosed with a major depressive disorder, and greater anhedonia increased the likelihood of being diagnosed with additional anxiety disorders and to a lesser extent, psychotic disorders. Results were consistent with research on the distinction of appetitive and aversive functioning, providing insight into the nature of PTSD.     

Biological attributions for postdeployment distress relate to higher likelihood of seeking mental health treatment in Iraq/Afghanistan service members/veterans

Service members/veterans (SM/Vs) underuse mental health care. Attribution theory suggests that attributions for psychological distress might inform help-seeking. Given recent mental health campaigns leveraging military values aimed at facilitating help-seeking for postdeployment distress, understanding how SM/Vs explain psychological distress may contribute to a better grasp of the low help-seeking rate in this population. The authors examined the association of biological and psychological attributions for postdeployment distress with help-seeking intentions from a mental health professional and medical doctor in 162 Iraq/Afghanistan SM/Vs. At the bivariate level, biological attributions were positively associated with help-seeking intentions from a mental health professional and medical doctor with small effect sizes. Psychological attributions were unrelated to help-seeking intentions from either provider. Path analysis revealed that biological attributions were positively correlated with help-seeking intentions from a medical doctor with a small effect size above and beyond the effects of psychological attributions and correlates. Biological attributions were also positively correlated with help-seeking intentions from a mental health professional with a small effect size but the significance value only trended toward significance (p = .06). Emphasizing the role of biology in postdeployment distress may promote help-seeking in SM/Vs, particularly help-seeking from medical professionals. Interventions that test the effectiveness of promoting biological explanations in campaigns aimed at increasing help-seeking may be a necessary next step in this area of inquiry.     

Depressive Symptomatology Mediates Associations With Community Reintegration in Veterans With TBI

Community reintegration (CR) is a challenge for military veterans with traumatic brain injury (TBI). Posttraumatic stress disorder (PTSD), depression, bodily pain, and limitations in physical functioning—common comorbidities with TBI in veterans—have all been associated with problems in CR, but their interrelationships are unclear. The role of depression as a possible mediator of effects on CR has not been examined. We tested depressive symptoms as a possible mediator of CR’s associations with physical limitations, PTSD, and bodily pain. This cross-sectional study used baseline data from a larger randomized controlled trial that evaluated the impact of an in-home intervention for veterans with TBI and their families. Eighty-three military veterans with TBI recruited from a medical rehabilitation service at an urban U.S. Department of Veterans Affairs medical center participated in the study. Interview instruments measured CR, depressive symptoms, physical limitations (limitations in physical functioning), bodily pain, quality of the relationship with key family members, and sociodemographic characteristics. PTSD was determined through review of the electronic medical record. Interview data were collected in veterans’ homes. Depressive symptoms totally mediated the association between physical limitations and CR and the association between PTSD and CR. The bodily pain–CR association was not significant after quality of relationship had been entered into the regression models. Findings suggest that interventions to increase CR of veterans with TBI should address depression, a treatable condition. Replication of our mediation findings in larger veteran and civilian samples with TBI is needed.     

Sequential validation of cluster analytic subtypes of homeless veterans

To identify subgroups within the homeless population, a number of researchers have employed cluster analytic statistical procedures. Although this is an appropriate application of cluster analysis, many studies have not employed important statistical safeguards against arbitrary results. This study demonstrates a cluster analytic procedure—sequential validation—that enhances the replicability, external validity, and cross-validity of cluster solutions. The procedure is applied to a nationwide sample of 745 homeless veterans. After 12 different clustering procedures were subjected to derivation, replication, external validation, and cross-validation phases, a 4-cluster Ward solution emerged as the most sound. Substantively, the clusters were an alcoholic subtype, a psychiatrically impaired subtype, a best functioning subtype, and a multiproblem subtype. The generalizability of these subgroups to other contexts was assessed by comparing them to subgroups identified in other homelessness research. Suggestions were made for improving the quality of cluster analytic research in community psychology.