Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic.

Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review.

In recent years, there has been a proliferation of research regarding transgender and gender nonconforming (TGNC) people. The stigma and legal discriminations that this population faces have obvious and documented repercussions for mental health. In 2015, the American Psychological Association (APA) published Guidelines for Psychological Practice with TGNC People. The APA noted that due to the nuances of working with TGNC youth and the dearth of related literature, the guidelines focus primarily on TGNC adults. To date, there has not been a systematic review of risk and resilience factors for mental health among TGNC children, adolescents, and young adults under the age of 25. Forty-four peer-reviewed articles met inclusion criteria for this systematic review, and were evaluated for their methodological rigor and their findings. Common risk factors for negative mental health variables included physical and verbal abuse, exposure to discrimination, social isolation, poor peer relations, low self-esteem, weight dissatisfaction, and age. Across studies, older children and adolescents tended to report higher rates of psychological distress. Resilience-promoting factors for mental health were also documented, including parent connectedness, social support, school safety and belonging, and the ability to use one's chosen name. By synthesizing the existing literature using a resilience-focused and minority stress framework, the present review provides clinicians and researchers with a coherent evidence-base to better equip them to promote psychological adaptation and wellbeing among TGNC youth.

Exploring the impact of trauma type and extent of exposure on posttraumatic alterations in 5-HT1A expression.

The long-term behavioral, psychological, and neurobiological effects of exposure to potentially traumatic events vary within the human population. Studies conducted on trauma-exposed human subjects suggest that differences in trauma type and extent of exposure combine to affect development, maintenance, and treatment of a variety of psychiatric syndromes. The serotonin 1-A receptor (5-HT1A) is an inhibitory G protein-coupled serotonin receptor encoded by the HTR1A gene that plays a role in regulating serotonin release, physiological stress responding, and emotional behavior. Studies from the preclinical and human literature suggest that dysfunctional expression of 5-HT1A is associated with a multitude of psychiatric symptoms commonly seen in trauma-exposed individuals. Here, we synthesize the literature, including numerous preclinical studies, examining differences in alterations in 5-HT1A expression following trauma exposure. Collectively, these findings suggest that the impact of trauma exposure on 5-HT1A expression is dependent, in part, on trauma type and extent of exposure. Furthermore, preclinical and human studies suggest that this observation likely applies to additional molecular targets and may help explain variation in trauma-induced changes in behavior and treatment responsivity. In order to understand the neurobiological impact of trauma, including the impact on 5-HT1A expression, it is crucial to consider both trauma type and extent of exposure.

Development of the Trauma-Related Anger Scale.

Anger is a pervasive problem following traumatic events. Previous research has demonstrated a moderate relationship between anger and posttraumatic stress disorder (PTSD), yet findings also highlight that anger has not been rigorously measured in the context of PTSD. Thus, this study concerns the development of a complimentary measure to assess anger in the context of PTSD. Participants were 435 undergraduate students. The participants were given a battery including the proposed scale and measures of trauma exposure, PTSD, anger, depression, anxiety, and social desirability. Exploratory factor analyses revealed a hierarchical, four-factor model provided the best fit to the data. The scale appeared psychometrically sound, with excellent internal consistency, good evidence of validity, and good model fit. This scale may provide implications for clinical work, specifically for the assessment and tracking of anger symptoms connected to PTSD. Additionally, this scale may assist with research by predicting treatment outcomes, aggression, and PTSD.

Network analysis of PTSD symptoms following mass violence.

OBJECTIVE: Network analysis is a useful tool for understanding how symptoms interact with one another to influence psychopathology. However, this analytic strategy has not been fully utilized in the PTSD field. The current study utilized network analysis to examine connectedness and strength among PTSD symptoms (employing both partial correlation and regression network analyses) among a community sample of students exposed to the 2007 Virginia Tech shootings. METHOD: Respondents (N = 4,639) completed online surveys 3-4 months postshootings, with PTSD symptom severity measured via the Trauma Symptom Questionnaire. RESULTS: Data were analyzed via adaptive least absolute shrinkage and selection operator (LASSO) and relative importance networks, as well as Dijkstra's algorithm to identify the shortest path from each symptom to all other symptoms. Relative importance network analysis revealed that intrusive thoughts had the strongest influence on other symptoms (i.e., had many strong connections [highest outdegree]) while computing Dijkstra's algorithm indicated that anger produced the shortest path to all other symptoms (i.e., the strongest connections to all other symptoms). CONCLUSION: Findings suggest that anger or intrusion likely play a crucial role in the development and maintenance of PTSD (i.e., are more influential within the network than are other symptoms). (PsycINFO Database Record

Predicting Grief Reactions One Year Following a Mass University Shooting: Evaluating Dose-Response and Contextual Predictors.

This study identifies risk factors for grief following a mass school shooting. Participants (N = 1,013) completed online questionnaires 3-4 months (Time 1) and 1 year (Time 2) post-shootings. We tested models predicting Time 2 grief reactions, exploring direct and indirect predictive effects of exposure variables (physical and social proximity) through hypothesized peritraumatic mediators (peritraumatic perceived threat to self or others) while controlling for Time 1 grief and posttraumatic stress (PTS) reactions, pretrauma vulnerabilities. Findings demonstrate that closer social proximity predicted higher levels of Time 2 grief, directly and indirectly through increasing peritraumatic perceived threat to others' safety. Physical proximity and peritraumatic threat to self did not predict Time 2 grief reactions. Implications for grief screening instruments and theory building research through identifying risk factors and causal mechanisms are discussed.

A Skill Set for Supporting Displaced Children in Psychological Recovery After Disasters.

Helping children, adolescents, and families displaced following a natural disaster is a daunting task made more challenging by the relatively small research base to inform services and interventions. This paper describes the current literature pertaining to intervention practices used with displaced youth. Where gaps in the literature exist, we pull from the more general research on relocation and post-disaster intervention to assist practitioners in tailoring their efforts. Specifically discussed are ways to enhance youth resilience, to help youth build new social connections and adjust to change and uncertainty while coping with trauma-related symptoms, and to meet needs through the systems in which children are embedded. The need for focused attention to cultural factors is discussed with an emphasis on collaborating with culture brokers.

Protective Factors, Coping Appraisals, and Social Barriers Predict Mental Health Following Community Violence: A Prospective Test of Social Cognitive Theory.

This study tested social cognitive theory of posttraumatic adaptation in the context of mass violence, hypothesizing that pre-event protective factors (general self-efficacy and perceived social support) would reduce posttraumatic stress symptoms (PTSS) and depression severity through boosting post-event coping self-efficacy appraisals (mediator). We qualified hypotheses by predicting that post-event social support barriers would disrupt (moderate) the health-promoting indirect effects of pre-event protective factors. With a prospective longitudinal sample, we employed path models with bootstrapping resampling to test hypotheses. Participants included 70 university students (71.4% female; 40.0% White; 34.3% Asian; 14.3% Hispanic) enrolled during a mass violence event who completed surveys one year pre-event and 5-6 months post-event. Results revealed significant large effects in predicting coping self-efficacy (mastery model, R2 = .34; enabling model, R2 = .36), PTSS (mastery model, R2 = .35; enabling model, R2 = .41), and depression severity (mastery model, R2 = .43; enabling model, R2 = .46). Overall findings supported study hypotheses, showing that at low levels of post-event social support barriers, pre-event protective factors reduced distress severity through boosting coping self-efficacy. However, as post-event social support barriers increased, the indirect, distress-reducing effects of pre-event protective factors were reduced to nonsignificance. Study implications focus on preventative and responsive intervention.

Do Negative Changes in Worldview Mediate Links Between Mass Trauma and Reckless Behavior? A Longitudinal Exploratory Study.

Trauma exposure heightens the risk of reckless behavior and is now included in DSM-5 posttraumatic stress disorder symptomatology. Individuals exposed to trauma may be likely to engage in reckless behavior because of negative changes in their worldview (referred to as disrupted worldview). The current study investigates the relationship between DSM-IV posttraumatic stress symptoms, disrupted worldview, and increased reckless behavior among 1145 students exposed to mass violence. Total posttraumatic stress symptomatology was associated with increased and persistent reckless behavior, supporting DSM-5 diagnostic inclusion. Although posttraumatic stress symptomatology predicted reckless behavior among those with varying levels of posttraumatic symptomatology, individuals with high symptomatology reported significantly higher recklessness. Disrupted worldview mediated the relationship between posttraumatic symptomatology and reckless behavior among individuals with high symptomatology, while only partially mediating the relationship among those with low symptomatology. These findings provide support for worldview disruptions as a mechanism by which prolonged reckless behavior may be manifested.

Psychometric Properties of the Child's Reaction to Traumatic Events Scale-Revised in English and Lugandan.

Brief and age-appropriate measures of trauma-related symptoms are useful for identifying children in need of clinical services. The current study examines the psychometric properties of the 23-item Child's Reaction to Traumatic Events Scale-Revised (CRTES-R). The CRTES-R includes subscales assessing hyperarousal, avoidance and intrusion. To date, no studies have examined the psychometric properties of this revised measure or cross-cultural differences in its factor structure. Two samples of (a) children (ages 6-21) who had experienced a hurricane in the USA or Grenada (N = 135), and (b) Ugandan children (ages 8-17) who had experienced a variety of traumatic events (N = 339) completed the CRTES-R in English or Lugandan. Confirmatory factor analysis supported an empirically adjusted model with three modified latent factors in both the English (χ2/df = 1.34, CFI = .90, RMSEA = .05) and Lugandan samples (χ2/df = 1.45, CFI = .93, RMSEA = .04). Although the analysis supported separate hyperarousal, avoidance and intrusion subscales, the items that loaded on each factor differed from the original CRTES-R subscales. The English version of the CRTES-R showed good concurrent validity with the Kauai Recovery Index measure of trauma symptoms. Those using the CRTES-R to assess children's experiences of the different symptom types should consider using the empirically-derived subscales described in this paper; however, those who wish to capture a broad spectrum of PTSD symptoms should consider using all the original CRTES-R items and calculating a total score.

Persistent grief in the aftermath of mass violence: the predictive roles of posttraumatic stress symptoms, self-efficacy, and disrupted worldview.

This study tested a conceptual model merging anxiety buffer disruption and social-cognitive theories to predict persistent grief severity among students who lost a close friend, significant other, and/or professor/teacher in tragic university campus shootings. A regression-based path model tested posttraumatic stress (PTS) symptom severity 3 to 4 months postshooting (Time 1) as a predictor of grief severity 1 year postshootings (Time 2), both directly and indirectly through cognitive processes (self-efficacy and disrupted worldview). Results revealed a model that predicted 61% of the variance in Time 2 grief severity. Hypotheses were supported, demonstrating that Time 1 PTS severity indirectly, positively predicted Time 2 grief severity through undermining self-efficacy and more severely disrupting worldview. Findings and theoretical interpretation yield important insights for future research and clinical application.

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI.

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children's posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.

When seeking influences believing and promotes posttraumatic adaptation.

BACKGROUND: Theory and evidence link social support processes and self-efficacy appraisals in the promotion of adaptation following traumatic events. Dynamic causal processes, however, have not been examined longitudinally or in the context of mass-violence. This study tested whether quantity of social support seeking indirectly reduced distress severity among student survivors of mass university shootings. Hypotheses specified that the indirect effects of social support seeking on distress severity would occur through positively influencing perceived social support and self-efficacy, and that these effects would emerge and become stronger as posttraumatic stress symptom severity increased. DESIGN: Path analysis via Mplus 7.2 was used to test the hypothesized moderated-serial-mediation model (conditional indirect effects). METHODS: The sample (N=1191) consisted of students enrolled at Virginia Tech during the 16 April 2007 shootings. Data were collected via online surveys at two time points, 3-4 months and 1-year post-shootings. RESULTS: Hypotheses were supported, showing that the indirect effects of social support seeking on distress reduction occurred through perceived social support, which in turn influenced self-efficacy. These effects emerged and grew in strength as PTS severity increased. CONCLUSIONS: Clinical implications, including the need to consider contextual determinants of posttraumatic recovery, are discussed.

The integration of mental and behavioral health into disaster preparedness, response, and recovery.

The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.

The H1N1 crisis: a case study of the integration of mental and behavioral health in public health crises.

In substantial numbers of affected populations, disasters adversely affect well-being and influence the development of emotional problems and dysfunctional behaviors. Nowhere is the integration of mental and behavioral health into broader public health and medical preparedness and response activities more crucial than in disasters such as the 2009-2010 H1N1 influenza pandemic. The National Biodefense Science Board, recognizing that the mental and behavioral health responses to H1N1 were vital to preserving safety and health for the country, requested that the Disaster Mental Health Subcommittee recommend actions for public health officials to prevent and mitigate adverse behavioral health outcomes during the H1N1 pandemic. The subcommittee's recommendations emphasized vulnerable populations and concentrated on interventions, education and training, and communication and messaging. The subcommittee's H1N1 activities and recommendations provide an approach and template for identifying and addressing future efforts related to newly emerging public health and medical emergencies. The many emotional and behavioral health implications of the crisis and the importance of psychological factors in determining the behavior of members of the public argue for a programmatic integration of behavioral health and science expertise in a comprehensive public health response.

Trends in serious emotional disturbance among youths exposed to Hurricane Katrina.

OBJECTIVE: To examine patterns and predictors of trends in DSM-IV serious emotional disturbance (SED) among youths exposed to Hurricane Katrina. METHOD: A probability sample of adult pre-hurricane residents of the areas affected by Katrina completed baseline and follow-up telephone surveys 18 to 27 months post-hurricane and 12 to 18 months later. Baseline adult respondents residing with children and adolescents (4-17 years of age) provided informant reports about the emotional functioning of these youths (n = 576) with the Strengths and Difficulties Questionnaire (SDQ). The surveys also assessed hurricane-related stressors and ongoing stressors experienced by respondent families. RESULTS: SED prevalence decreased significantly across survey waves from 15.1% to 11.5%, although even the latter prevalence was considerably higher than the pre-hurricane prevalence of 4.2% estimated in the US National Health Interview Survey. Trends in hurricane-related SED were predicted by both stressors experienced in the hurricane and ongoing stressors, with SED prevalence decreasing significantly only among youths with moderate stress exposure (16.8% versus 6.5%). SED prevalence did not change significantly between waves among youths with either high stress exposure (30.0% versus 41.9%) or low stress exposure (3.5% versus 3.4%). Pre-hurricane functioning did not predict SED persistence among youths with high stress exposure, but did predict SED persistence among youth with low-moderate stress exposure. CONCLUSIONS: The prevalence of SED among youths exposed to Hurricane Katrina remains significantly elevated several years after the storm despite meaningful decrease since baseline. Youths with high stress exposure have the highest risk of long-term hurricane-related SED and consequently represent an important target for mental health intervention.

Serious emotional disturbance among youths exposed to Hurricane Katrina 2 years postdisaster.

OBJECTIVE: To estimate the prevalence of serious emotional disturbance (SED) among children and adolescents exposed to Hurricane Katrina along with the associations of SED with hurricane-related stressors, sociodemographics, and family factors 18 to 27 months after the hurricane. METHOD: A probability sample of prehurricane residents of areas affected by Hurricane Katrina was administered a telephone survey. Respondents provided information on up to two of their children (n = 797) aged 4 to 17 years. The survey assessed hurricane-related stressors and lifetime history of psychopathology in respondents, screened for 12-month SED in respondents' children using the Strengths and Difficulties Questionnaire, and determined whether children's emotional and behavioral problems were attributable to Hurricane Katrina. RESULTS: The estimated prevalence of SED was 14.9%, and 9.3% of the youths were estimated to have SED that is directly attributable to Hurricane Katrina. Stress exposure was associated strongly with SED, and 20.3% of the youths with high stress exposure had hurricane-attributable SED. Death of a loved one had the strongest association with SED among prehurricane residents of New Orleans, whereas exposure to physical adversity had the strongest association in the remainder of the sample. Among children with stress exposure, parental psychopathology and poverty were associated with SED. CONCLUSIONS: The prevalence of SED among youths exposed to Hurricane Katrina remains high 18 to 27 months after the storm, suggesting a substantial need for mental health treatment resources in the hurricane-affected areas. The youths who were exposed to hurricane-related stressors, have a family history of psychopathology, and have lower family incomes are at greatest risk for long-term psychiatric impairment.

Exposure to hurricane-related stressors and mental illness after Hurricane Katrina.

CONTEXT: Uncertainty exists about the prevalence, severity, and correlates of mental disorders among people exposed to Hurricane Katrina. OBJECTIVE: To estimate the prevalence and associations between DSM-IV anxiety-mood disorders and hurricane-related stressors separately among prehurricane residents of the New Orleans metropolitan area and the remainder of the areas in Alabama, Louisiana, and Mississippi affected by Katrina. DESIGN: Community survey. SETTING AND PARTICIPANTS: A probability sample of 1043 English-speaking prehurricane residents of the areas affected by Hurricane Katrina was administered via telephone survey between January 19 and March 31, 2006. The survey assessed hurricane-related stressors and screened for 30-day DSM-IV anxiety-mood disorders. MAIN OUTCOME MEASURES: The K6 screening scale of anxiety-mood disorders and the Trauma Screening Questionnaire scale for posttraumatic stress disorder (PTSD), both calibrated against blinded structured clinical reappraisal interviews to approximate the 30-day prevalence of DSM-IV disorders. RESULTS: Prehurricane residents of the New Orleans metropolitan area were estimated to have a 49.1% 30-day prevalence of any DSM-IV anxiety-mood disorder (30.3% estimated prevalence of PTSD) compared with 26.4% (12.5% PTSD) in the remainder of the sample. The vast majority of respondents reported exposure to hurricane-related stressors. Extent of stressor exposure was more strongly related to the outcomes in the New Orleans metropolitan area subsample than the remainder of the sample. The stressors most strongly related to these outcomes were physical illness/injury and physical adversity in the New Orleans metropolitan area subsample and property loss in the remainder of the sample. Sociodemographic correlates were not explained either by differential exposure or reactivity to hurricane-related stressors. CONCLUSIONS: The high prevalence of DSM-IV anxiety-mood disorders, the strong associations of hurricane-related stressors with these outcomes, and the independence of sociodemographics from stressors argue that the practical problems associated with ongoing stressors are widespread and must be addressed to reduce the prevalence of mental disorders in this population.

Characterizing time in longitudinal trauma research.

Despite the proliferation of longitudinal trauma research, careful attention to timing of assessments is often lacking. Patterns in timing of assessments, alternative time structures, and the treatment of time as an outcome are discussed and illustrated using trauma data.