Moral injury, race-related stress and post-traumatic stress disorder in a trauma-exposed Black population.

BACKGROUND: Race-related stress (RRS) is an unrecognized source of moral injury (MI)-or the emotional and/or spiritual suffering that may emerge after exposure to events that violate deeply held beliefs. Additionally, MI has not been explored as a mechanism of risk for post-traumatic stress disorder (PTSD) in trauma-exposed civilians. We examined relations among exposure to potentially morally injurious events (moral injury exposure, MIE), related distress (moral injury distress, MID), and RRS in Black Americans. Potential indirect associations between RRS and PTSD symptoms via MID were also examined. METHODS: Black Americans (n = 228; 90.4% female; Mage = 31.6 years. SDage = 12.8 years) recruited from an ongoing study of trauma completed measures assessing civilian MIE and MID, RRS, and PTSD. Bivariate correlations were conducted with MIE and MID, and mediation analysis with MID, to examine the role of MI in the relationship between RRS and PTSD symptom severity. RESULTS: MIE was significantly correlated with cultural (r = 0.27), individual (r = 0.29), and institutional (r = 0.25) RRS; MID also correlated with cultural (r = 0.31), individual (r = 0.31), and institutional (r = 0.26) RRS (ps < 0.001). We found an indirect effect of RRS on PTSD symptoms via MID (ß = 0.10, p < 0.005). CONCLUSIONS: All types of RRS were associated with facets of MI, which mediated the relationship between RRS and current PTSD symptoms. MI may be a potential mechanism through which RRS increases the risk for PTSD in Black individuals.

Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat.

BACKGROUND: Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury. METHODS: Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials. RESULTS: Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity. CONCLUSIONS: Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.

Civilian moral injury: associations with trauma type and high-frequency heart rate variability in two trauma-exposed community-based samples.

BACKGROUND: Moral injury exposure (MIE) and distress (MID) may indirectly affect the relationship between trauma exposure and alterations in autonomic regulation [assessed via high-frequency heart rate variability (hfHRV)] in civilians, but this has not been tested in prior research. We conducted two exploratory studies to examine trauma types' associations with MIE and MID among civilian medical patients (Study 1) and explore how these facets may indirectly affect the relationship between trauma type and hfHRV among civilians seeking mental health services (Study 2). METHODS: Participants recruited from a public hospital and/or community advertisements (Study 1, n = 72, 87.5% Black, 83.3% women; Study 2, n = 46, 71.7% Black, 97.8% women) completed measures assessing trauma type, MIE, and MID. In Study 1, trauma types that emerged as significant correlates of MIE and MID were entered into separate linear regression analyses. Trauma types identified were included as predictors in indirect effects models with MIE or MID as the mediator and resting hfHRV (assayed via electrocardiography) as the outcome. RESULTS: Childhood sexual abuse emerged as the only significant predictor of MIE, b = 0.38, p < 0.001; childhood sexual abuse, b = 0.26, p < 0.05, and adulthood sexual assault, b = 0.23, p < 0.05 were significant predictors of MID. Participants with greater MIE and MID demonstrated lower hfHRV. Adulthood sexual assault showed an indirect effect on hfHRV through MID, B = -0.10, s.e. = 0.06, 95%CI (-0.232 to -0.005). CONCLUSIONS: Moral injury was uniquely associated with sexual violence and lower hfHRV in civilians. Data highlight moral injury as a pathway through which autonomic dysregulation may emerge and its salience for trauma treatment selection.

Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members.

Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly within community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n = 177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r = .23, p ≤ .025, and depersonalization, r = .25, p ≤ .001, and MID was correlated with depersonalization, r = .19, p ≤ .025. Sex moderated each association, with stronger associations observed for female participants. Findings suggest that moral injury appraisals are linked to more severe dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.

Differing associations of depersonalization with physiological response during rest and breath-focused mindfulness in a trauma-exposed female population.

BACKGROUND: Dissociative and posttraumatic stress disorder (PTSD) symptoms are commonly co-occurring responses to psychological trauma. Yet, these two groups of symptoms appear to be related to diverging patterns of physiological response. To date, few studies have examined how specific dissociative symptoms, namely, depersonalization and derealization, relate to skin conductance response (SCR), a marker of autonomic function, within the context of PTSD symptoms. We examined associations among depersonalization, derealization, and SCR during two conditions - resting control and breath-focused mindfulness - in the context of current PTSD symptoms. METHODS: Sixty-eight trauma-exposed women (82.4% Black; Mage = 42.5, SDage = 12.1) were recruited from the community for a breath-focused mindfulness study. SCR data were collected during alternating resting control and breath-focused mindfulness conditions. Moderation analyses were conducted to examine relations among dissociative symptoms, SCR, and PTSD for these different conditions. RESULTS: Moderation analyses revealed that depersonalization was linked to lower SCR during resting control, B = 0.0005, SE = 0.0002, p = .006, in participants low-to-moderate PTSD symptoms; however, depersonalization was associated with higher SCR during breath-focused mindfulness, B = -0.0006, SE = 0.0003, p = .029, in individuals with similar levels of PTSD symptoms. No significant interaction between derealization and PTSD symptoms on SCR was observed. CONCLUSIONS: Depersonalization symptoms may associate with physiological withdrawal during rest, but greater physiological arousal during effortful emotion regulation in individuals with low-to moderate levels of PTSD, which has significant implications for barriers to treatment engagement as well as treatment selection in this population.

Neurophysiological changes associated with vibroacoustically-augmented breath-focused mindfulness for dissociation: targeting interoception and attention.

BACKGROUND: Dissociative symptoms can emerge after trauma and interfere with attentional control and interoception; disruptions to these processes are barriers to mind-body interventions such as breath-focused mindfulness (BFM). To overcome these barriers, we tested the use of an exteroceptive augmentation to BFM, using vibrations equivalent to the amplitude of the auditory waveform of the actual breath, delivered via a wearable subwoofer in real time (VBFM). We tested whether this device enhanced interoceptive processes, attentional control and autonomic regulation in trauma-exposed women with dissociative symptoms. METHODS: 65 women, majority (82%) Black American, aged 18-65 completed self-report measures of interoception and 6 BFM sessions, during which electrocardiographic recordings were taken to derive high-frequency heart rate variability (HRV) estimates. A subset (n = 31) of participants completed functional MRI at pre- and post-intervention, during which they were administered an affective attentional control task. RESULTS: Compared to those who received BFM only, women who received VBFM demonstrated greater increases in interoception, particularly their ability to trust body signals, increased sustained attention, as well as increased connectivity between nodes of emotion processing and interoceptive networks. Intervention condition moderated the relationship between interoception change and dissociation change, as well as the relationship between dissociation and HRV change. CONCLUSIONS: Vibration feedback during breath focus yielded greater improvements in interoception, sustained attention and increased connectivity of emotion processing and interoceptive networks. Augmenting BFM with vibration appears to have considerable effects on interoception, attention and autonomic regulation; it could be used as a monotherapy or to address trauma treatment barriers.

The mediating role of emotion dysregulation in the association between trait mindfulness and PTSD symptoms among trauma-exposed adults.

OBJECTIVES: Growing evidence of the effectiveness of mindfulness-based interventions for posttraumatic stress disorder (PTSD) warrants greater understanding of factors relevant to the relation between trait mindfulness and PTSD, such as emotion dysregulation (ED). The goal of this study was to examine associations between trait mindfulness, ED, and PTSD symptoms across two samples of trauma-exposed adults. METHODS: Participants for Sample 1 (n = 39, 90% women, 100% Black) and Sample 2 (n = 60, 100% women, 87% Black) were recruited from an urban hospital in the South. Trait mindfulness, ED, and PTSD were assessed. RESULTS: Across both samples, mindfulness and ED were significantly associated with overall PTSD severity (r = -.49 and r = -.42, ps = .001; r = .53 and r = .51, ps < .001, respectively) in the expected direction. In Sample 1, mindful nonjudgment and difficulty with emotion regulation strategies showed the strongest associations with overall PTSD severity as well as symptom clusters. In Sample 2, mindful acceptance and all ED dimensions (except non-awareness) showed strong associations with overall PTSD severity and particularly with negative cognitions and mood symptoms. In both samples, ED mediated the association between mindfulness and overall PTSD severity (Sample 1: ab = -.15, 95%CI [-.35, -.02]; Sample 2: ab = -.11, 95%CI [-.22, -.04]). CONCLUSIONS: These findings demonstrate the important role of ED in the relation between trait mindfulness and PTSD symptoms among trauma-exposed adults. They highlight the value of examining ED as a mechanism of change in mindfulness-based interventions for PTSD. CLINICAL TRIALS REGISTRATION INFORMATION: Sample 1: NCT03922581, April 22, 2019; NCT03938350, May 6, 2019; Sample 2: NCT02754557, April 28, 2016.

Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior.

Background: Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations 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.

Antecedentes: El daño moral (DM) describe el sufrimiento emocional, espiritual y social que puede surgir después de un trauma psicológico. Investigaciones previas en poblaciones militares indican la relevancia del DM para los desenlaces psicológicos adversos, como trastorno de estrés postraumático (TEPT) y las conductas suicidas, y muestran evidencia de que el DM es un constructo único. Se han implementado mínimos estudios de DM en civiles, usualmente restringidos a pequeñas muestras con un conjunto específico de experiencias traumáticas, a pesar de la relevancia conceptual de DM para las reacciones de trauma no militares más amplias (p.Ej., Sentimientos de traición hacia un perpetrador de abuso sexual).Objetivo: Para abordar este problema, evaluamos el DM en civiles expuestos a trauma para examinar las formas en que este constructo se relacionaba y se diferenciaba de los problemas relacionados con el trauma y el estrés traumático, incluidos el trastorno de estrés postraumático y la depresión.Método: Adaptamos una escala de DM existente, la Escala de eventos de daños morales y administramos esta medida a 81 hombres y mujeres junto con medidas de exposición al trauma, TEPT y depresión, y también preguntamos a los participantes sobre intentos suicidas pasados.Resultados: Observamos que tanto una exposición mayor como la angustia relacionada con eventos de potencial daño moral se asociaron con mayor exposición a trauma, particularmente al maltrato infantil, así como a psicopatología postraumática y depresiva. Sin embargo, incluso después de tener en cuenta los síntomasde TEPT actuales y depresión, la exposición a DM (F = 6.05, p = .017) fue significativamente mayor entre los participantes que habían intentado suicidio previamente.Conclusiones: Estos datos piloto revelan las formas en que el DM se asocia con la exposición al trauma, TEPT y depresión y resaltan la importancia del DM en la población civil. De manera similar, estos datos demuestran la relevancia única del DM para los comportamientos suicidas, independientemente de la psicopatología postraumática, lo que indica que este constructo puede ser un contribuyente subestudiado del riesgo de suicidio en la población civil.

Validation and Construct Validity of the Posttraumatic Avoidance Behaviour Questionnaire in a Sample of Trauma-Exposed Black Women.

Engaging in posttraumatic avoidance behaviors after a traumatic incident is associated with posttraumatic stress disorder (PTSD) outcomes. Given the inherent limitations in the scope of the two-item assessment of posttraumatic avoidance used in commonly administered measures of PTSD symptoms, the 25-item Posttraumatic Avoidance Behaviour Questionnaire (PABQ) was developed to assess a range of avoidance behaviors, including avoidance of visual and sensory reminders, trauma-related thoughts, and agoraphobia, as well as avoidance related to the home, sleep, and social interaction. However, the PABQ's utility is limited by its lack of (a) construct validity and (b) validation in diverse samples. To address these limitations, we examined the psychometric properties of PABQ scores in a sample of trauma-exposed Black women (N = 601, M age = 41 years). Confirmatory factor analyses indicated that the original seven-factor model fit the data well when Item 8 was excluded, χ2 (231, N = 602) = 497.86, RMSEA = .04, 90% CI [.04, .05], CFI = .99, TLI = .989, WRMR = .939, but reliability estimates were variable (i.e., Cronbach's αs = .70-.91). In addition, we found support for convergent validity, clinical validity, and incremental validity. These results provide evidence for the psychometric strengths of the PABQ in minority samples and suggest that it is a valid assessment of posttraumatic avoidance in Black women.