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Unlabelled: Moral injury is an emerging construct related to negative consequences associated with war-zone stressors that transgress military veterans' deeply held values/beliefs. Given the newness of the construct, there is a need for instrumentation that might assess morally injurious experiences (MIEs) in this population. Drawing on a community sample of 131 Iraq and/or Afghanistan Veterans and clinical sample of 82 returning Veterans, we conducted an initial psychometric evaluation of the newly developed Moral Injury Questionnaire-Military version (MIQ-M)-a 20-item self-report measure for assessing MIEs. Possibly due to low rates of reporting, an item assessing sexual trauma did not yield favourable psychometric properties and was excluded from analyses. Veterans in the clinical sample endorsed significantly higher scores across MIQ-M items. Factor analytic results for the final 19 items supported a unidimensional structure, and convergent validity analyses revealed that higher scores (indicative of more MIEs) were correlated with greater general combat exposure, impairments in work/social functioning, posttraumatic stress and depression in the community sample. In addition, when controlling for demographics, deployment-related factors and exposure to life threat stressors associated with combat, tests of incremental validity indicated that MIQ-M scores were also uniquely linked with suicide risk and other mental health outcomes. These findings provide preliminary evidence for the validity of the MIQ-M and support the applicability of this measure for further research and clinical work with Veterans., Key Practitioner Message: Military service can confront service members with experiences that undermine their core sense of humanity and violate global values and beliefs. These types of experiences increase the risk for posttraumatic maladjustment in this population, even when accounting for rates of exposure to life threat traumas. Moral injury is an emerging construct to more fully capture the many possible psychological, ethical, and spiritual/existential challenges among persons who served in modern wars and other trauma-exposed professional groups. There is currently a need for psychometrically sound instrumentation for assessing morally injurious experiences (MIEs). The Moral Injury Questionnaire - Military Version (MIQ-M) was developed to provide a tool for assessing possible MIEs among military populations. This study provides preliminary evidence of the validity - including factorial, concurrent, and incremental - and clinical utility of the MIQ-M for further applications in clinical and research contexts., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objective: To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD)., Method: A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via videoteleconferencing (n = 61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. The primary clinical outcome was reduction of anger difficulties, as measured by the anger expression and trait anger subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008., Results: Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance., Conclusions: Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations., ((c) Copyright 2010 Physicians Postgraduate Press, Inc.)

Male inpatient veterans with chronic combat-related post-traumatic stress disorder (PTSD) participated in trauma focus group treatment and were assessed immediately before group participation and after group completion at time of discharge. Standard measures of core PTSD symptoms, depression, and anxiety were used. In addition, changes in PTSD symptoms were tracked on a weekly basis for the duration of group participation. Results indicated that a single direct elicitation of war-related traumatic memories in a group setting was not associated with symptom worsening. However, veterans also did not show improvement in symptoms severity. Possible reasons for this lack of impact are discussed along with implications for future treatment design and evaluation.

This study tested a family-based skills-building intervention in veterans with chronic combat-related posttraumatic stress disorder (PTSD). Veterans and a family member were randomly assigned to 1 of 3 conditions: (a) waiting list, (b) 18 sessions of twice-weekly exposure therapy, or (c) 18 sessions of twice-weekly exposure therapy followed by 16 sessions of behavioral family therapy (BFT). Participation in exposure therapy reduced PTSD positive symptoms (e.g., reexperiencing and hyperarousal) but not PTSD negative symptoms. Positive symptom gains were maintained at 6-month follow-up. However, participation in BFT had no additional impact on PTSD symptoms.

Background: Elevated cholesterol levels have been reported in panic disorder and anger attacks, but not major depression. No data have been reported in posttraumatic stress disorder (PTSD)., Methods: Seventy-three male Vietnam veterans with chronic (PTSD) had serum lipid screening upon entry to a 90-day inpatient program., Results: Elevated cholesterol, low-density lipoprotein, triglycerides, and reduced high-density lipoprotein, were frequent in Vietnam veterans with chronic PTSD and are significant risk factors for coronary artery disease., Conclusions: Routine lipid screening may be warranted in this at-risk population. Altered lipid levels may result from activation of the noradrenergic system.

Relationships among pretrauma risk factors (e.g., family instability, childhood antisocial behavior), war-zone stressors (e.g., combat, perceived threat), posttrauma resilience-recovery variables (e.g., hardiness, social support), and posttraumatic stress disorder (PTSD) symptom severity were examined. Data from a national sample of 432 female and 1,200 male veterans were analyzed using structural equation modeling. For both genders, direct links to PTSD from pretrauma, war-zone, and posttrauma variable categories were found; several direct associations between pretrauma and posttrauma variables were documented. Although war-zone stressors appeared preeminent for PTSD in men, posttrauma resilience-recovery variables were more salient for women. Researchers, policymakers, and clinicians are urged to take a broad view on trauma and its sequelae, especially regarding possible multiple exposures over time and the depletion and availability of important resources.

This study investigated the relationship between combat exposure and adult antisocial behavior in a sample of 2,490 male Army veterans of the Vietnam War who completed questionnaires about their psychological functioning. After adjustment for history of childhood behavior problems, posttraumatic stress disorder diagnosis, and demographic and military characteristics, it was found that veterans who experienced high and very high levels of combat were twice as likely to report adult antisocial behavior as veterans with no or low levels of combat and were also more likely to meet criteria for antisocial personality disorder. The results indicate that exposure to traumatic events during late adolescence or early adulthood is associated with multiple adult adjustment problems in vocational, interpersonal, and societal functioning. Treatment focusing on the effects of the trauma is likely to be necessary but not sufficient for improving affected veterans' behavior.

Structural equation modeling was used to examine relationships among prewar factors, dimensions of war-zone stress, and current posttraumatic stress disorder (PTSD) symptomatology using data from 1,632 female and male participants in the National Vietnam Veterans Readjustment Study. For men, previous trauma history (accidents, assaults, and natural disasters) directly predicted PTSD and also interacted with war-zone stressor level to exacerbate PTSD symptoms for high combat-exposed veterans. Male veterans who entered the war at a younger age displayed more symptoms. Family instability, childhood antisocial behavior, and age had indirect effects on PTSD for men. For women, indirect prewar effects emanated from family instability. More attention should be given to critical developmental conditions, especially family instability and earlier trauma exposure, in conceptualizing PTSD in adults.

Current literature on the etiology of combat-related PTSD strongly implicates combat trauma exposure as a primary etiological factor. However, studies of premilitary variables have produced conflicting results, perhaps in part due to methodological inconsistencies and failure to employ standardized measures. The present study examines one premilitary variable, childhood physical abuse history. Using a standardized measure developed by child abuse researchers, forty-five percent of veterans with PTSD were identified as recipients of abusive physical punishment during childhood. A positive correlation between physical abuse history and severity of combat-related PTSD was found. These preliminary findings set the stage for further investigation of the child abuse variable and underscore the need for treatment of veterans with combat-related PTSD which addresses developmental traumagenic events.

A recently developed statistical method for single-case subject designs based on classical test theory was used to examine the efficacy of imaginal exposure treatment for posttraumatic stress disorder (PTSD) in four Vietnam veterans. The method was sensitive to intraindividual changes across different outcome measures even when relatively few data points were available. Two veterans clearly improved from exposure and maintained their gains at 3- and 15-month follow-ups. One veteran improved marginally, whereas one veteran's symptoms worsened. Changes in heart rate monitored over the first two imaginal exposures indicated that veterans with greater heart-rate habituation responded better to exposure than did veterans with less or no habituation. The results suggest that the statistical method illustrated here has some advantages over other methods (e.g., visual inspection, time-series analysis) for examining clinical interventions in single-case designs.

Assessment data from 118 Vietnam-era veterans seeking psychological services at two Los Angeles Veterans Administration Medical Centers were analyzed to examine the potential relationships between number of preadult and adult antisocial behaviors, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) criteria for antisocial personality disorder, level of combat exposure, and development of combat-related post-traumatic stress disorder (PTSD). Results of hierarchical regression analyses indicated that combat exposure level was related significantly to PTSD symptomatology, whereas number of preadult antisocial behaviors was not. However, both combat exposure level and preadult behaviors, which were not correlated significantly, were related significantly to number of adult antisocial behaviors. There were no significant interaction effects. Results were consistent with a theoretical model of PTSD development that emphasizes the role of trauma vs. premorbid characterological factors. In addition, the significant association between combat exposure and adult antisocial behavior indicates that trauma may play a role in the development and/or maintenance of adult antisocial behaviors observed in some Vietnam veterans.

This paper presents a review of empirical literature that deals with etiological factors in combat-related post-traumatic stress disorder (PTSD). Variables implicated in PTSD from three time frames, premilitary, military, and postmilitary, are identified, and findings from relevant research are discussed. There is consistency across studies in showing significant correlations between PTSD and combat exposure and post-military psychosocial adjustment. Less consistent are the findings with regard to relationships between premilitary psychosocial factors and PTSD. Recent findings from studies that have explored possible physiological correlates of PTSD also are discussed. Based on current literature, implications for future research on etiological factors in combat-related PTSD are presented.

Although symptoms of Post-Traumatic Stress Disorder are expected to persist for many years, there is often no systematic assessment of Vietnam veterans' combat experiences. A study of 43 help-seeking Vietnam veterans revealed that a reliable assessment of war trauma, the Combat Exposure Scale, could be constructed from dichotomous questions about seven stressful events. Scale scores related significantly to current diagnosis of PTSD and intensity of symptoms. The Guttman scaling technique resulted in an ordering of events that provides clinically relevant information about the nature of trauma in the Vietnam War.