The role of United States identity in adjustment among Veterans.

Given over 2.77 million US service members have been deployed in the past 20 years and the intense process of reintegration to civilian life, understanding factors that contribute to Veterans' mental health and substance use is critical. This study sought to understand the effects of US identity exploration, US identity commitment, US identity affirmation, and US identity centrality on substance use and symptoms of depression and anxiety. The sample consisted of 195 US military Veterans (n = 184, 53.3% women; 73.3% White; Mage = 35.12 years, SD = 9.60 years). Bivariate correlations indicated US identity affirmation was negatively associated with substance use and symptoms of depression and anxiety whereas US identity centrality was positively correlated with alcohol use. Utilizing structural equation model, US identity affirmation and US identity centrality were, respectively, negatively and positively associated with alcohol use, substance use, and symptoms of depression and anxiety. Partially consistent with our hypothesis, US identity exploration was positively associated with symptoms of anxiety. In contrast to our hypothesis, US identity commitment was not significantly associated with any outcome. Results are discussed in terms of important directions for identity research in the transition to civilian life.

Associations Among Exposure to Potentially Morally Injurious Experiences, Spiritual Injury, and Alcohol Use Among Combat Veterans.

Potentially morally injurious experiences (PMIEs) are events that may violate deeply held values or belief systems. Combat engagement places service members at a heightened risk for PMIE exposure. Exposure to PMIEs may elicit internal conflict between moral beliefs and experiences and, if unresolved, conflict may manifest as feelings of guilt, shame, and spiritual or existential crisis. Further, distress caused by these experiences may promote harmful behaviors (e.g., excessive alcohol use), which may serve as attempts to cope with PMIEs veterans have witnessed or participated in. The present study examined a sequential mediation model in which combat exposure was associated with alcohol use (i.e., alcohol consumption, dependence symptoms, and alcohol-related problems) via PMIE exposure and spiritual injury (e.g., alienation from and/or anger towards respective higher power) in a community sample of 380 recent-era combat veterans. Multiple-group sequential mediation was then used to examine whether the model fit similarly across men and women. Exposure to PMIEs and spiritual injury sequentially mediated the association between combat and alcohol; higher levels of PMIE exposure and spiritual injury were associated with increased alcohol use, R2 = .17, f2 = 0.07. The multiple-group model showed that these associations significantly varied between genders such that the mediation was only significant among men. The results indicated that PMIEs and spiritual injury were associated with increased alcohol use, but these associations differed as a function of gender. Future research is needed to refine our understanding of moral and spiritual injury and explore possible risk and protective factors.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Las Asociaciones entre la Exposición a Experiencias Potencialmente Dañinas Moralmente, Daño Espiritual, y el Uso de Alcohol Entre Combatientes Veteranos EXPOSICION, DAÑO ESPIRITUAL, Y USO DE ALCOHOL Las experiencias potencialmente dañinas moralmente (PMIEs en su sigla en inglés) son eventos que pueden transgredir los valores profundamente arraigados o los sistemas de creencias. La participación en combates posiciona a los miembros en servicio en un más alto riesgo de exposición a las PMIEs. La exposición a las PMIEs puede provocar conflictos internos entre las creencias morales y las experiencias y, si no son resueltos, el conflicto puede manifestarse como sentimientos de culpa, vergüenza, y crisis espirituales o existenciales. Además, el malestar causado por estas experiencias puede promover conductas dañinas (por ej., uso excesivo de alcohol), las cuales pueden servir como intentos para lidiar con las PMIEs que los veteranos han observado o en las que ellos han participado. En el presente estudio, en una muestra comunitaria de 380 combatientes veteranos de la era reciente, se examinó un modelo de mediación secuencial en el cual la exposición al combate fue asociada con el uso de alcohol (por ej., consumo de alcohol, síntomas de dependencia, y problemas asociados al alcohol) por medio de la exposición a las PMIEs y el daño espiritual (por ej., alienación y enojo contra una deidad). Una mediación secuencial de grupos múltiples fue luego usada para examinar si el modelo se ajustaba similarmente entre hombres y mujeres. La exposición a las PMIEs y el daño espiritual mediaron secuencialmente la asociación entre el combate y el alcohol; niveles más altos de exposición a las PMIEs y el daño espiritual se asociaron con mayor uso de alcohol, R2 = .17, f2 = 0.07. El modelo de grupos múltiples mostró que estas asociaciones variaron significativamente entre los géneros, de manera tal que la mediación fue solamente significativa entre los hombres. Los resultados indican que las PMIEs y el daño espiritual se encuentran asociados con un mayor uso de alcohol, pero estas asociaciones son diferentes dependiendo del género. Las futuras investigaciones son necesarias para mejorar nuestro entendimiento del daño moral y espiritual y explorar posibles factores de riesgo y protectores.

Social concerns about anxious arousal explain the association between neural responses to anxious arousal pictures and social anxiety.

Cognitive theories propose that social anxiety disorder involves heightened attention to anxious arousal symptoms due to worries that they may evoke rejection from others. Supporting this, studies have shown that social anxiety is related to greater attention to representations of anxious arousal and to anxiety sensitivity social concerns, which refers to sensitivity to feelings of anxious arousal during social situations. However, this has not yet been tested using neural indices of attention to images depicting anxious arousal. To examine these associations, the current study examined early and sustained attentional bias to anxious arousal images using the P2 and the late positive potential (LPP), respectively. Electroencephalogram data were collected while a non-clinical sample of undergraduate students (N = 106) viewed images of people exhibiting anxious arousal in addition to blocks of negative and neutral images from the IAPS. The neural response to anxious arousal images was isolated using residual scores (e.g., using linear regression to predict the P2 elicited by anxious arousal images from the P2 elicited by neutral images (P2neutral→AA) or negative images (P2negative→AA), then saving the unstandardized residuals). There was an indirect effect of the P2neutral→AA and P2negative→AA waveforms that was explained by anxiety sensitivity social concerns. Additionally, there was an indirect effect of both LPP waveforms on social anxiety symptoms during the early time window of the LPP (400-700 ms). At the later time window of the LPP (700-1000 ms), there was an indirect effect of the LPPneutral→AA residual waveform, but not the LPPnegative→AA, on social anxiety symptoms.

Understanding the Dimensions of Post-Event Processing: Applying a Bifactor Modeling Approach to the EPEPQ-15.

Social anxiety disorder is maintained in part by rumination about past social experiences, known as post-event processing. The Extended Post-Event Processing Questionnaire (EPEPQ-15) assesses post-event processing as three correlated factors. Competing against this structure is a bifactor model that has not yet been evaluated for the EPEPQ-15. These models were tested for the conventional state version of the EPEPQ-15 and a new trait version in two separate samples (Ns = 327 and 351). In both samples, the fit of the bifactor model was better than that of correlated factor models. Moreover, the results did not support the group factors, indicating that a unidimensional interpretation of the EPEPQ-15 is most appropriate. The general dimension of the EPEPQ-15 was highly correlated with social interaction anxiety, beliefs related to social anxiety, anticipatory processing, and safety behaviors. These results overall suggest post-event processing is best conceptualized as a unitary construct.

Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans.

Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one's core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one's response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% (n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.

Killing during combat and negative mental health and substance use outcomes among recent-era veterans: The mediating effects of rumination.

OBJECTIVE: Although killing in combat is associated with negative mental health outcomes and hazardous alcohol use, mechanisms that underlie this risk are not well understood. To our knowledge, this present brief report is the first to use mediation analysis to examine associations between killing in combat, distinct facets of rumination (problem-focused thoughts, counterfactual thinking, repetitive thoughts, and anticipatory thoughts), and negative mental health outcomes (i.e., depression, anxiety, PTSD, suicidality) and hazardous alcohol use. METHOD: Participants were a community sample of 283 military personnel (158 males [60.31%]; mean age = 32.61 [SD = 7.11]) who had deployed in support of recent wars in Iraq or Afghanistan. Participants completed an online self-report survey. RESULTS: Three rumination facets (i.e., problem-focused thoughts, counterfactual thinking, and anticipatory thoughts) uniquely (controlling for effects of other rumination facets) mediated the associations between killing in combat and negative mental health outcomes and hazardous alcohol use. Taken together, killing in combat was associated with higher levels of each rumination facet, which in turn were distinctly associated with more negative symptoms of mental health and more hazardous drinking (problem-focused thoughts were the only facet to mediate all effects). Beyond these significant mediation effects, killing in combat still had a significant direct effect on every outcome. CONCLUSION: These findings provide preliminary support for associations between killing in combat and negative mental health outcomes and hazardous alcohol use. Furthermore, rumination (particularly problem-focused thoughts) may be an important consideration in the evaluation and care of recent-era combat veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Moral injury and suicidality among combat-wounded veterans: The moderating effects of social connectedness and self-compassion.

OBJECTIVE: Among combat veterans, moral injury (i.e., the guilt, shame, inability to forgive one's self and others, and social withdrawal associated with one's involvement in events that occurred during war or other missions) is associated with a host of negative mental health symptoms, including suicide. To better inform and tailor prevention and treatment efforts among veterans, the present study examined several potential risk (i.e., overidentification and self-judgment) and protective (i.e., self-kindness, mindfulness, common humanity, and social connectedness) variables that may moderate the association between moral injury and suicidality. METHOD: Participants were 189 combat wounded veterans (96.8% male; mean age = 43.14 years) who had experienced one or more deployments (defined as 90 days or more). Nearly all participants reported a service-connected disability (n = 176, 93.1%) and many had received a Purple Heart (n = 163, 86.2%). RESULTS: Within a series of moderation models, we found 3 statistically significant moderation effects. Specifically, the association between self-directed moral injury and suicidality strengthened at higher levels of overidentification, that is, a tendency to overidentify with one's failings and shortcomings. In addition, the association between other-directed moral injury and suicidality weakened at higher levels of mindfulness and social connectedness. CONCLUSIONS: These findings provide insight on risk and protective factors that strengthen (risk factor) or weaken (protective factor) the association between moral injury and suicidality in combat-wounded veterans. Taken together, mindfulness, social connectedness, and overidentification are relevant to understand the increased/decreased vulnerability of veterans to exhibit suicidality when experiencing moral injury. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychometric Properties of a Modified Moral Injury Questionnaire in a Military Population.

Moral injury (MI) results from perpetration of or exposure to distressing events, known as morally injurious events (MIEs), that challenge moral beliefs and values. Due to the type of involvement in recent military conflicts, many veterans report MIEs that may cause dissonance and, in turn, MI. Although two existing measures assess MIEs, neither currently assesses the defining characteristics of MI (i.e., guilt, shame, difficulty forgiving self and others, and withdrawal). The present study reports the initial psychometric test of a modified version (Robbins, Kelley, Hamrick, Bravo, & White, 2017) of the Moral Injury Questionnaire - Military version (MIQ-M; Currier, Holland, Drescher, & Foy, 2015) in a sample of 328 military personnel (e.g., veterans, National Guard/reservists, active duty members). The MIQ-M was modified to assess both MIEs and the defining characteristics of MI. Exploratory factor analyses suggested a three-factor model of MIEs consisting of Atrocities of war, Psychological consequences of war, and Leadership failure or betrayal. The modified MIQ-M factors were correlated with defining characteristics of MI. In addition, each MIE factor and associated defining characteristics of MI were positively correlated with symptoms of posttraumatic stress disorder, depression, and anxiety, as well as substance use. The modified MIQ-M is a reliable measure of MI that is comprised of three subscales that are associated with, but distinct from, mental health outcomes. Although findings are promising, further research evaluating the applicability of the modified MIQ-M in clinical settings is required to establish construct validity of the defining characteristics and secondary manifestations of MI.

Parents' Reports of Children's Internalizing Symptoms: Associations with Parents' Mental Health Symptoms and Substance Use Disorder.

This brief report examined the unique associations between parents' ratings of child internalizing symptoms and their own depression and anxiety in families with parental substance use disorder (SUD). Further, we examined whether parental SUD (father only, mother only, both parents) was related to discrepancy in mothers' and fathers' reports of children's internalizing symptoms. Participants were 97 triads (fathers, mothers) in which one or both parents met criteria for SUD. Polynomial regression analyses were conducted to examine whether father-mother reports of child internalizing symptoms had unique associations with parents' own symptoms of depression and anxiety while controlling for child gender, child age, and SUD diagnoses. Controlling for fathers' symptoms and other covariates, mothers experiencing more depression and anxiety symptoms reported more symptoms of child internalizing symptoms than did fathers. Mothers' and fathers' SUD was associated with higher anxiety symptoms among mothers after controlling for other variables. A second set of polynomial regressions examined whether father-mother reports of child internalizing symptoms had unique associations with parents' SUD diagnoses while controlling for child gender and child age. After controlling for mothers' symptoms and other covariates, parents' reports of children's internalizing symptoms were not significantly associated with either parent's SUD or parental SUD interactions (i.e., both parents have SUD diagnoses). Taken together, mothers' ratings of children's internalizing symptoms may be accounted for, in part, by her reports of depression and anxiety symptoms.