Research at CDP: Difficulties with Emotion Regulation Within PTSD Clusters and Moral Injury Subtypes
Recently, the CDP collaborated with colleagues within the VA Healthcare System, University of Rochester, and Louisiana State University to examine the role of difficulties with emotion regulation on military connected individuals with PTSD and/or moral injury. This study expanded on previous findings from Protopopescu and colleagues’ (2021) work in the Canadian Armed Forces, which found a positive correlation between difficulties with emotion regulation and the PTSD subscales but, interestingly, not to moral injury.
Our team was intrigued by these findings, especially given the strong emotional aspects inherent to moral injury. Guilt and shame are particularly prevalent among individuals with a moral injury, and it is hypothesized that some individuals may struggle to manage their influence on one another and other negative emotions such as depression, anxiety, and anger. However, our understanding of the relationship between difficulties with emotion regulation and moral injury has been limited by the lack of available research in this area. If moral injury is related to difficulties with emotion regulation, this might provide a treatment target to reduce moral injury-related distress.
Our study, led by Dr. Rachel Boska, examined a sample of US military connected individuals (active duty and Veterans) recruited through Qualtrics with an email invitation. All participants had deployed as part of their military service and reported clinically significant PTSD symptoms and/or moral injury distress. Participants were largely male, white, and middle-aged with a history of service in the US Army. Approximately 25% only met the clinical cutoff for PTSD (PTSD Checklist-5 score of 32 or above), 40% only met the clinical cutoff for moral injury (Moral Injury Events Scale of 27 or above), and 36% met the cutoffs for both PTSD and moral injury.
Rather than examining PTSD and moral injury as singular constructs, we examined the clusters using the measures’ subscales. PTSD clusters included intrusions/re-experiencing, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Moral injury subscales included other’s transgressions, self-transgressions, and betrayal. In contrast to Protopopescu and colleagues’ finding that moral injury was not related to difficulties with emotion regulation, we found that all PTSD and moral injury subscales were significantly associated with difficulties with emotion regulation such that as PTSD and moral injury symptom severity increased so did difficulties with emotion regulation. The differences in results may be in part due to the smaller sample size available to Protopopescu and colleagues or the timing of the studies (Protopopescu occurred after the conclusion of Canada’s involvement in the War on Terror; Boska occurred while the US was still engaged). It is also possible that the discrepancies in results may be due to differences in US and Canadian service members’ deployment experiences, such as the time engaged in the War on Terror (US: approximately 20 years; Canada: approximately 13 years) or the conflicts in which they participated (Canada did not participate in Operation Iraqi Freedom). However, we further proposed that the divergent results may be due to differences in the service member’s perspective on the conflict. US service members deployed in support of a US-led conflict following an attack on the US, but Canadian service members deployed in support of an allied nation. We suggest that this difference might affect one’s rationalization of and response to their deployment experiences.
We further examined these relationships using a hierarchical regression that included all PTSD and moral injury subscales and covariates (i.e., how religious they viewed themselves, age, sex, and race). Alterations in arousal and reactivity (Cluster E of the PTSD criteria) and self-transgression moral injuries were significantly associated with difficulties with emotion regulation beyond the effects of the other included variables. One possible explanation for the relationship to alterations in arousal and reactivity is the inclusion of irritable outbursts as a symptom of arousal and reactivity. These results also suggest that those who violate their own morals or core beliefs may have greater difficulties with emotion regulation than other types of moral injury.
Clinical Takeaway:
Treatment plans that target improving emotion regulation may be helpful for patients experiencing distress related to a self-transgression moral injury. More research is needed to understand the potential benefit of improving emotion regulation in these patients.
Want to learn more?
Read the article at: Boska, R. L., Bishop, T. M., Capron, D. W., Paxton Willing, M. M., &
Ashrafioun, L. (2024). Difficulties with emotion regulation within PTSD clusters and moral
injury subtypes. Military Psychology, 1–9. Advance online publication.
https://doi.org/10.1080/08995605.2024.2322904
Related research: Protopopescu, A., Boyd, J. E., O’Connor, C., Rhind, S. G., Jetly, R., Lanius,
R. A., & McKinnon, M. C. (2021). Examining the associations among moral injury, difficulties
with emotion regulation, and symptoms of PTSD, depression, anxiety, and stress among
Canadian military members and veterans: A preliminary study. Journal of Military Veteran and
Family Health, 7(2), 71–80. https://doi.org/ 10.3138/jmvfh-2020-0036
Funding Statement
The work summarized above was in part supported by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award No. [W81XWH-16-2-0004: PI Boska]. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the MSRC or the Department of Defense.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan M. Paxton Willing, Ph.D., MPH, is a Research Psychologist (HJF) with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Willing’s research broadly examines mental health in military populations. Her primary research interests include the development, correlates, and treatment of sleep and posttraumatic stress disorder in service members, with a particular emphasis on posttraumatic nightmares.
Recently, the CDP collaborated with colleagues within the VA Healthcare System, University of Rochester, and Louisiana State University to examine the role of difficulties with emotion regulation on military connected individuals with PTSD and/or moral injury. This study expanded on previous findings from Protopopescu and colleagues’ (2021) work in the Canadian Armed Forces, which found a positive correlation between difficulties with emotion regulation and the PTSD subscales but, interestingly, not to moral injury.
Our team was intrigued by these findings, especially given the strong emotional aspects inherent to moral injury. Guilt and shame are particularly prevalent among individuals with a moral injury, and it is hypothesized that some individuals may struggle to manage their influence on one another and other negative emotions such as depression, anxiety, and anger. However, our understanding of the relationship between difficulties with emotion regulation and moral injury has been limited by the lack of available research in this area. If moral injury is related to difficulties with emotion regulation, this might provide a treatment target to reduce moral injury-related distress.
Our study, led by Dr. Rachel Boska, examined a sample of US military connected individuals (active duty and Veterans) recruited through Qualtrics with an email invitation. All participants had deployed as part of their military service and reported clinically significant PTSD symptoms and/or moral injury distress. Participants were largely male, white, and middle-aged with a history of service in the US Army. Approximately 25% only met the clinical cutoff for PTSD (PTSD Checklist-5 score of 32 or above), 40% only met the clinical cutoff for moral injury (Moral Injury Events Scale of 27 or above), and 36% met the cutoffs for both PTSD and moral injury.
Rather than examining PTSD and moral injury as singular constructs, we examined the clusters using the measures’ subscales. PTSD clusters included intrusions/re-experiencing, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Moral injury subscales included other’s transgressions, self-transgressions, and betrayal. In contrast to Protopopescu and colleagues’ finding that moral injury was not related to difficulties with emotion regulation, we found that all PTSD and moral injury subscales were significantly associated with difficulties with emotion regulation such that as PTSD and moral injury symptom severity increased so did difficulties with emotion regulation. The differences in results may be in part due to the smaller sample size available to Protopopescu and colleagues or the timing of the studies (Protopopescu occurred after the conclusion of Canada’s involvement in the War on Terror; Boska occurred while the US was still engaged). It is also possible that the discrepancies in results may be due to differences in US and Canadian service members’ deployment experiences, such as the time engaged in the War on Terror (US: approximately 20 years; Canada: approximately 13 years) or the conflicts in which they participated (Canada did not participate in Operation Iraqi Freedom). However, we further proposed that the divergent results may be due to differences in the service member’s perspective on the conflict. US service members deployed in support of a US-led conflict following an attack on the US, but Canadian service members deployed in support of an allied nation. We suggest that this difference might affect one’s rationalization of and response to their deployment experiences.
We further examined these relationships using a hierarchical regression that included all PTSD and moral injury subscales and covariates (i.e., how religious they viewed themselves, age, sex, and race). Alterations in arousal and reactivity (Cluster E of the PTSD criteria) and self-transgression moral injuries were significantly associated with difficulties with emotion regulation beyond the effects of the other included variables. One possible explanation for the relationship to alterations in arousal and reactivity is the inclusion of irritable outbursts as a symptom of arousal and reactivity. These results also suggest that those who violate their own morals or core beliefs may have greater difficulties with emotion regulation than other types of moral injury.
Clinical Takeaway:
Treatment plans that target improving emotion regulation may be helpful for patients experiencing distress related to a self-transgression moral injury. More research is needed to understand the potential benefit of improving emotion regulation in these patients.
Want to learn more?
Read the article at: Boska, R. L., Bishop, T. M., Capron, D. W., Paxton Willing, M. M., &
Ashrafioun, L. (2024). Difficulties with emotion regulation within PTSD clusters and moral
injury subtypes. Military Psychology, 1–9. Advance online publication.
https://doi.org/10.1080/08995605.2024.2322904
Related research: Protopopescu, A., Boyd, J. E., O’Connor, C., Rhind, S. G., Jetly, R., Lanius,
R. A., & McKinnon, M. C. (2021). Examining the associations among moral injury, difficulties
with emotion regulation, and symptoms of PTSD, depression, anxiety, and stress among
Canadian military members and veterans: A preliminary study. Journal of Military Veteran and
Family Health, 7(2), 71–80. https://doi.org/ 10.3138/jmvfh-2020-0036
Funding Statement
The work summarized above was in part supported by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award No. [W81XWH-16-2-0004: PI Boska]. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the MSRC or the Department of Defense.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan M. Paxton Willing, Ph.D., MPH, is a Research Psychologist (HJF) with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Willing’s research broadly examines mental health in military populations. Her primary research interests include the development, correlates, and treatment of sleep and posttraumatic stress disorder in service members, with a particular emphasis on posttraumatic nightmares.