Post-Traumatic Stress Syndrome may be a “Moral Injury” Too

Post-traumatic stress syndrome may have a moral component that adds to the victim’s suffering, according to a new study from the Veterans Administration.

Dr. Shira Maguen and her colleagues are studying more than 2600 Marines and sailors before and after they experience combat in the wars in the Middle East. Preliminary findings indicate that three months after they return home, approximately 7% developed posttraumatic stress syndrome, a mental disorder characterized by nightmares, flashbacks, insomnia, difficulties in relationships and anger management, hypervigilance, and other symptoms that often make it impossible to function at home or on the job. These symptoms have been linked to their fears of being killed, or having friends killed in combat, and not necessarily inner conflicts about their role in battle.

This new research is finding that many have feelings of shame and guilt, so-called “moral injuries.” They may feel distressed that they survived when others died, or that they unintentionally killed innocent people, or did not intervene when others did so.

“How do they come to terms with that?” said Navy Capt. Bill Nash, a psychiatrist and co-author of the study. “They have to forgive themselves for pulling the trigger.”

Previous research has indicated that not just veterans of combat experience moral conflicts within posttraumatic stress syndrome. People who survived the 9-11 attacks in New York and natural disasters such as Hurricane Katrina tell their therapists they feel guilty that others died instead of them. Victims of violent crime often regret they did not intervene to help others during the incident.

The committee that writes the Diagnostic and Statistical Manual of Mental Disorders is considering a change in the diagnostic criteria for posttraumatic stress syndrome in the next edition, due to come out in 2013. If such changes are approved, symptoms of the disorder may include feelings of shame and guilt, according to David Spiegel, a member of the committee writing that section of the manual used by doctors to diagnose mental illness. Such a change would also alter the way psychiatrists and therapists approach treatment.

According to statistics from the Armed Services, about half of the veterans returning from Iraq and Afghanistan have mental health issues, with the most common being post-traumatic stress syndrome and substance abuse. Posttraumatic stress syndrome is increasing by 5% every three months among veterans, amounting to 40,000 new cases a year. So far the VA has treated 211,819 or about 16% of the 1.3 million combat veterans for this disorder. Demand for services is intense, and a veteran usually has to wait at least two weeks for treatment to become available.