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This study examined the impact of killing on posttraumatic stress symptomatology (PTSS), depression, and alcohol use among 317 U.S. Gulf War veterans. Participants were obtained via a national registry of Gulf War veterans and were mailed a survey assessing deployment experiences and postdeployment mental health. Overall, 11% of veterans reported killing during their deployment. Those who reported killing were more likely to be younger and male than those who did not kill. After controlling for perceived danger, exposure to death and dying, and witnessing killing of fellow soldiers, killing was a significant predictor of PTSS, frequency and quantity of alcohol use, and problem alcohol use. Military personnel returning from modern deployments are at risk of adverse mental health symptoms related to killing in war. Postdeployment mental health assessment and treatment should address reactions to killing in order to optimize readjustment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Impact of Killing on Mental Health Symptoms in Gulf War Veterans
Shira Maguen
San Francisco VA Medical Center and University of
California, San Francisco
Dawne S. Vogt, Lynda A. King, Daniel W. King,
and Brett T. Litz
National Center for PTSD, Department of Veterans Affairs
Boston Healthcare System and Massachusetts Veterans
Epidemiological Research and Information Center, and Boston
University School of Medicine
Sara J. Knight and Charles R. Marmar
San Francisco VA Medical Center and University of California, San Francisco
This study examined the impact of killing on posttraumatic stress symptomatology (PTSS), depression,
and alcohol use among 317 U.S. Gulf War veterans. Participants were obtained via a national registry of
Gulf War veterans and were mailed a survey assessing deployment experiences and postdeployment
mental health. Overall, 11% of veterans reported killing during their deployment. Those who reported
killing were more likely to be younger and male than those who did not kill. After controlling for
perceived danger, exposure to death and dying, and witnessing killing of fellow soldiers, killing was a
significant predictor of PTSS, frequency and quantity of alcohol use, and problem alcohol use. Military
personnel returning from modern deployments are at risk of adverse mental health symptoms related to
killing in war. Postdeployment mental health assessment and treatment should address reactions to killing
in order to optimize readjustment.
Keywords: killing, veterans, gulf war, PTSD, alcohol
Military personnel involved in war kill as part of their mission,
although few studies have examined the rates of those involved in
killing or the mental health impact of taking another life. In a
population-based epidemiological study of Gulf War veterans,
14% of male soldiers reported killing another person (Carney et
al., 2003), and these numbers are even higher when surveying
combat veterans. Hoge and colleagues (2004) found that 77% to
87% of soldiers in infantry units returning from Operation Iraqi
Freedom (OIF) reported shooting or directing fire at the enemy,
48% to 65% reported being responsible for the death of an enemy
combatant, and 14% to 28% reported being responsible for the
death of a noncombatant.
The few studies that have examined killing in the war zone as a
risk factor for combat-related posttraumatic stress disorder (PTSD)
have found that taking another life is an important and robust
predictor (Fontana & Rosenheck, 1999; MacNair, 2002). Each of
these studies controlled for exposure to other combat variables to
ensure that the results were not attributable to combat exposure
alone, but due to the particular effects of killing. More specifically,
in their model of war zone stressors and PTSD, Fontana and
Rosenheck (1999) demonstrated that the impact of killing differ-
entially impacted PTSD symptoms compared with other combat-
related factors, such as exposure to death or perceived threat.
While killing had a strong direct effect on PTSD, exposure to death
and injury and perceived threat did not. Our goal was to determine
whether these results would replicate in Gulf War veterans.
Thus far, the few studies that exist mainly examined the rela-
tionship between killing and PTSD, although alcohol problems and
depression also are common and important to assess in veterans
returning from overseas deployments. After controlling for general
combat experiences, Maguen and colleagues (2010, 2009) found
an association between killing and problem drinking among Viet-
nam and Iraq War veterans. Although PTSD and depression are
often highly comorbid, Maguen and colleagues (2010, 2009) did
not find an association between killing and depression among
either Vietnam or Iraq War veterans. Consequently, our goal was
to determine whether these alcohol and depression results would
replicate in Gulf War veterans.
There are a number of variables that are important to consider
when evaluating the mental health impact of killing. First, it is
This article was published Online First October 4, 2010.
Shira Maguen, Sara J. Knight, and Charles R. Marmar, San Francisco
VA Medical Center, San Francisco, California, and University of Califor-
nia, San Francisco; Dawne S. Vogt, Lynda A. King, Daniel W. King, and
Brett T. Litz, National Center for PTSD, Department of Veterans Affairs
Boston Healthcare System and Massachusetts Veterans Epidemiological
Research and Information Center, Boston, Massachusetts; Boston Univer-
sity School of Medicine.
This study was funded by a VA Health Services Research and Devel-
opment (HSR&D) Career Development Award (Shira Maguen) and by the
Department of Defense (U.S. Army Medical Research and Materiel Com-
mand) in collaboration with the Department of Veterans Affairs (DoD-87,
“Measurement and Validation of Psychosocial Risk and Resilience Factors
Associated with Physical and Mental Health and Health-Related Quality of
Life in Gulf War Veterans” (Daniel W. King). We thank Jeane Bosch and
Thomas Metzler for their assistance with this article.
Correspondence concerning this article should be addressed to Shira
Maguen, San Francisco VA Medical Center, PTSD Program (116-P), 4150
Clement Street, San Francisco, CA 94121. E-mail:
Psychological Trauma: Theory, Research, Practice, and Policy In the public domain
2011, Vol. 3, No. 1, 21–26 DOI: 10.1037/a0019897
important to ensure that the impact of killing is not attributable to
related variables, such as exposure to death or witnessing killing.
For example, one study found that among Gulf War veterans, 52%
of men and 45% of women saw dead bodies or individuals who
were seriously maimed or injured, with 22% of men and 14% of
women witnessing someone dying (Carney et al., 2003). Another
study found that among soldiers serving in Operation Iraqi Free-
dom (OIF), 77% reported seeing dead bodies and 56% reported
witnessing killing (Maguen et al., 2010). Consequently, in this
study, we controlled for exposure to death and dying and witness-
ing killing in our examination of the association between killing
and a variety of postdeployment mental health measures.
Perceived threat is another variable that has been found to be
important in predicting PTSD among veterans and is often in-
cluded in comprehensive models of postdeployment functioning
(e.g., King, King, Foy, Keane & Fairbank, 1999; King, King,
Gudanowski & Vreven, 1995; Kulka et al., 1990). Perceived
threat, which is a subjective response to a hostile environment and
an important marker of peritraumatic response, is consistently
associated with the onset of adverse mental health symptoms
across samples (e.g., Holbrook, Hoyt, Stein, & Sieber, 2001;
Marmar, Weiss, Metzler, Ronfelt, & Foreman, 1996; McCaslin et
al., 2006). As a result, we also controlled for perceptions of danger
in our exploration of the impact of killing on postdeployment
mental health.
The purpose of this study was to examine the relationship
between killing and postdeployment mental health in Gulf War
veterans, after controlling for important variables such as per-
ceived danger, exposure to death and dying, and witnessing killing.
To our knowledge, this is the first study to examine the conse-
quences of taking another life among Gulf War veterans. Although
prior research has mainly focused on PTSD, our goal was to
replicate and extend these findings by examining the impact of
killing on additional postdeployment mental health measures, such
as depression and alcohol use. Identifying the impact of killing has
important implications for the evaluation and treatment of our
newly returning service members.
Procedure and Participants
Participants were obtained via the Defense Manpower Data
Center and a national registry of Gulf War veterans. Mangione’s
(1998) multistep method was employed to optimize participant
response rate. First, potential participants were mailed a letter
explaining the study’s purpose. More specifically, participants
were told that the study would pertain to multiple aspects of their
deployment experiences. Confidentiality was assured, and the vol-
untary nature of participation was emphasized. Second, the origi-
nal letter was followed by a survey package containing a collection
of stressor and health outcome measures. Third, a reminder card
was sent, followed by a remailing of the package to nonrespon-
dents, and then a final reminder card. Of the 495 veterans who
were identified, 320 returned completed questionnaires in 2002.
Our study sample included 317 veterans who responded to the
question about killing in the war zone. Although posttraumatic
stress symptomatology (PTSS) was assessed among the entire
sample, depression and alcohol questionnaires were only admin-
istered to half the sample as part of a purposeful design to reduce
time burden on participants while still retaining a broad array of
measures. All procedures and measures were approved by the VA
Boston Healthcare System Institutional Review Board and con-
formed to standards for the protection of human subjects. Partic-
ipants were 64.8% Caucasian, 15.2% Black, 13.7% Hispanic, 1.6%
American Indian/Alaskan Native, and 1% Asian/Pacific Islander;
3.8% identified as Other. For other demographic characteristics of
participants, see Table 1.
Veterans reported age, gender, race/ethnicity, educational status,
and relationship status. They also were asked to respond to four
questions, each indexing a particular component of their war zone
experience: (a) perceived danger, (b) exposure to death and dying,
(c) witnessing killing of a fellow soldier, and (d) killing. Perceived
danger was assessed using the item, “I felt that I was in danger of
being killed or wounded” and was rated on a five-point Likert
scale, ranging from strongly disagree to strongly agree. Those
endorsing somewhat agree or strongly agree were rated as expe-
riencing perceived danger when percentages of individuals expe-
riencing each item were calculated, and this item was used as a
continuous variable in the regression equations. Exposure to death
and dying was assessed using the item, “I was exposed to the sight,
sound, or smell of dying men and women” and was rated on a
dichotomous scale. Witnessing killing of a fellow soldier was
assessed using the item, “I personally witnessed someone from my
unit or an ally unit being seriously wounded or killed” and was
rated on a dichotomous scale. Killing was assessed using the item,
“I killed or think I killed someone in combat” and also was rated
on a dichotomous scale.
PTSS was assessed using the PTSD Checklist, Military Version,
a 17-item measure (PCL; Blanchard, Jones-Alexander, Buckley, &
Forneris, 1996; Weathers et al., 1993). Each item was rated on a
five-point Likert scale, with responses ranging from not at all to
extremely, and participants were asked to rate PTSS over the last
3 months. The PCL is widely used as a screen for PTSD, has been
shown to have very good internal consistency, and correlates
strongly with other measures of PTSD symptoms (Weathers et al.,
1993). The PCL also demonstrates high diagnostic efficiency (i.e.,
.90; Blanchard et al., 1996). For the purposes of this study, we used
a recommended cutoff score of 50 when reporting a positive screen
for PTSD (Weathers et al., 1993) and a continuous symptom score
in our regression analysis. The internal consistency of the PCL for
our sample was .96.
Depression symptoms were assessed using an adapted version
of the Beck Depression Inventory-Primary Care (BDI-PC; Beck,
Steer, Ball, Ciervo, & Kabat, 1997). The original seven items from
the BDI-PC were used with a variation in the response format.
More specifically, participants were asked to rate symptoms over
the last three months (e.g., “In the last three months, I have felt like
a failure”), and unlike the original, each item was rated on a
five-point scale, with responses ranging from strongly disagree to
strongly agree. The BDI has excellent psychometric properties
(Beck, Steer, & Garbin, 1988). We used a cutoff score of four
when determining a positive screen for depression (Beck, Guth,
Steer, & Ball, 1997), with somewhat or strongly agree being used
as the threshold for a positive symptom score; we also include a
stricter criterion for depression, using only those who responded
strongly agree to at least four items. In our regression analysis, we
used a continuous depression symptom score. The internal consis-
tency of the BDI-PC for our sample was .91.
Alcohol use was assessed using two separate measures: (a) an
index of frequency and quantity of alcohol use and (b) the CAGE
(Ewing, 1984), a measure of problem alcohol use.
Frequency and quantity of alcohol use was assessed using the
following two questions: (a) “In the past three months how often
have you had a drink containing alcohol?” with responses rated on
a five-point scale ranging from never to four or more times a week
and (b) “In the past three months, how many drinks containing
alcohol have you had on a typical day when you were drinking?”
with responses rated on a five-point scale ranging from none to 7
or more. For the purposes of this study, a product of these two
questions was used in the multiple regression equation indexing
alcohol use, given that there is precedent for examining the product
term of alcohol frequency and quantity among veterans (e.g.,
Savarese, Suvak, King, & King, 2001).
The CAGE is a four-item measure in which participants were
asked four dichotomously rated questions related to their alcohol
use prior to deployment and in the present. Questions included
indicators of problem alcohol use, such as feelings of guilt in
reaction to drinking, criticism from others regarding drinking, and
wanting to cut down on drinking. For the purposes of this study,
responding positively to two or more questions in the present was
considered a positive screen for problem alcohol use (e.g., Hearne,
Connolly, & Sheehan, 2002), although we also report results for a
cut off score of one, given that there is also precedent of using a
lower threshold with military samples (e.g., LeardMann, Smith,
Smith, Wells, & Ryan, 2009). In our regression analyses, we used
a continuous measure of problem alcohol use prior to deployment
and in the present. The alpha reliability of this measure was .76
prior to deployment and .81 in the present.
Data Analysis
All of the analyses in this study were performed using the
statistical software package SPSS version 17.0 for Windows. First,
we calculated percentages of individuals who reported exposure to
indices of combat and killing in war. Next, we computed the
percentage of individuals in our sample who met screening criteria
for PTSD, depression, and problem alcohol use. Finally, we con-
ducted a series of regression analyses to identify predictors of each
of the postdeployment mental health measures.
We conducted four hierarchical regressions to determine
whether reported killing was significantly associated with PTSS,
depression, frequency and quantity of alcohol use, and current
problem alcohol use. In these analyses, we included related expo-
sure variables to ensure that the results were not attributable to
merely participating in combat (i.e., we controlled for perceived
danger, exposure to death and dying, and witnessing killing of a
fellow soldier).
In the first step of each regression, we entered demographic
variables (i.e., age, gender, race/ethnicity, educational status, and
relationship status). In the two regression equations related to
alcohol use, we also were able to control for prior problem drink-
ing in the first step. In the second step, we controlled for related
exposure variables; and in the third step we entered reported
In this study, 46% of veterans reported perceiving danger during
their deployment, 42% reported exposure to death and dying, 19%
reported witnessing killing of a fellow soldier, and 11% reported
killing in combat. We compared those who endorsed killing to
those who did not and found that younger, F(1, 313) 5.41, p
.05, and male veterans,
(1) 4.18, p.05, were more likely
to report killing during the Gulf War than their counterparts.
Table 1
Sociodemographic Characteristics of Gulf War Veterans
Killed (n34) Did not kill (n283) Total (n317)
Age, M(SD)
41 (8.8) 45 (8.9) 44 (9.0)
Male 30 (88) 202 (72) 234 (74)
Female 4 (12) 79 (28) 83 (26)
White 22 (65) 178 (65) 202 (65)
Minority 12 (35) 96 (35) 108 (35)
Some high school 0 (0) 1 (.4) 1 (.3)
High school graduate 5 (15) 17 (6) 22 (7)
Vocation or technical training 2 (6) 27 (10) 30 (10)
Some college 15 (44) 119 (42) 135 (43)
Four-year college graduate 5 (15) 45 (16) 50 (16)
Some graduate or professional school 3 (9) 18 (6) 21 (7)
Graduate or professional degree 4 (12) 54 (19) 58 (18)
Marital status
Single 9 (27) 74 (26) 84 (26)
Married 25 (74) 207 (74) 233 (74)
Veterans also endorsed a wide range of mental health symp-
toms: 20% met threshold screening criteria for PTSS, 45% for
depression (11% using a stricter cutoff score; see measures sec-
tion), and 6% for current problem alcohol use (11% using a less
strict cutoff score; see measures section). Veterans reported drink-
ing an average of 2 to 3 times a month (SD 1.35), with the mean
amount of alcohol consumed being 1 to 2 drinks per occasion
(SD 1.08).
In the final hierarchical regression model predicting PTSS
(Table 2), older age, ethnic minority status, lower education, per-
ceived danger, and exposure to death and dying were each signif-
icant predictors. Reported killing remained significant, even after
controlling for perceived danger, exposure to death, and witness-
ing killing.
In the final hierarchical regression model predicting depression
symptoms (Table 2), being single, perceived danger, and exposure
to death and dying were each significant predictors. However,
neither witnessing killing nor reported killing were significant
predictors of depression symptoms.
In the final hierarchical regression models predicting current
frequency and quantity of alcohol use and current problem alcohol
use (Table 3), after controlling for prior problem drinking, reported
killing was the only significant predictor of each alcohol-related
We used the false discovery rate procedure specified by Benja-
mini and Hochberg (1995) to adjust for multiple comparisons in
our four outcomes, and we found that the three significant killing
findings each remained significant.
Despite the fact that the Gulf War was a relatively short and
targeted mission, a significant number of veterans reported killing
during their deployment, with even larger numbers reporting ex-
posure to death and dying and witnessing killing of a fellow
soldier. Killing in combat was a significant predictor of PTSS and
multiple indicators of alcohol use, even after controlling for highly
salient variables such as perceived danger, exposure to death and
dying, and witnessing killing, suggesting that taking a life in
combat is a critical ingredient in the development of postdeploy-
ment mental health concerns.
Our finding that killing is associated with PTSS is consistent with
the few existing studies that evaluated the mental health impact of
taking a life (e.g., Fontana & Rosenheck, 1999; MacNair, 2002),
although this is the first study to document this association in Gulf
War veterans. This also is the first study demonstrating an asso-
ciation between killing and several indices of alcohol use in Gulf
War veterans. Of particular importance, killing was the only war
zone variable that significantly predicted alcohol use, even when
including important war zone experiences and controlling for
preexisting alcohol problems. Given recent findings of elevated
alcohol rates in veterans returning from modern deployments (e.g.,
Calhoun, Elter, Jones, Kudler, & Straits-Tröster, 2008; Maguen et
al., 2010), the impact of killing seems critical and may play an
important role in the evaluation and treatment of veterans with
problem alcohol use.
The relationship between killing and alcohol use may reflect a
method for veterans who are impacted by killing in war to regulate
difficult emotions. Indeed, prior researchers have postulated that
alcohol abuse may represent an effort to self-medicate avoidance
or hyperarousal symptoms associated with PTSD (Bremner et al.,
1996; Kulka et al., 1990). Another possibility is that the relation-
ship between killing in war and alcohol use is mediated by vari-
ables such as impulsivity or invincibility. A recent study postulated
that exposure to violent combat, including killing, may alter an
individual’s perceived threshold of invincibility, thereby increas-
ing the likelihood of engaging in high risk behavior, including
increased alcohol use (Killgore et al., 2008). It is important to note
that these authors did not find a relationship between killing and
impulsivity, suggesting that invincibility may be the important
We did not find an association between killing and depression,
which is consistent with past studies (Maguen et al., 2010, 2009).
Although depression is highly associated with PTSD and the two
are often comorbid, when depression is examined as a whole, it is
not associated with killing. It is important to note that while PTSD
is always event-based, depression is not. A diagnosis of PTSD
cannot be given without a potentially traumatic event. Relatedly,
depression may be better predicted by other variables, such as
family history, rather than by killing. While killing and exposure to
killing were not strongly associated with depression, exposure to
Table 2
Hierarchical Regression Models of Posttraumatic Stress Symptomatology (PTSS) and Depression
PTSS Depression
(Step 1) (Step 2) (Final model) R
)(Step 1) (Step 2) (Final model) R
1. Age .01 .10 .11
.17 .07 .07 .10
Gender .06 .08 .10 .05 .08 .08
Ethnicity .18
.02 .02 .02
Education .26
.15 .10 .10
Marital status .13
.09 .09 .15 .16
2. Perceived danger .32
Exposure to death .25
Witnessing killing .12
.10 .05 .05
3. Killing .11
.00 .23
Note. For final models, F(9, 297) 20.05, p.01 for PTSS; F(9, 148 4.86, p.01 for Depression, Ethnicity: 0 Caucasian,1ethnic minority;
Gender: 0 male,1female; Spouse: 0 single,1married/in a relationship. Numbers vary because of missing data.
death seemed to be a strong predictor, suggesting that some aspects
of exposure to combat increase risk for depression, while others do
There are several limitations of this study that should be noted.
First, the current study was retrospective; consequently recall bias
should be taken into account when interpreting these results.
Relatedly, because these data were collected several years after the
war, measures may reflect more chronic symptomology. Second,
this investigation was conducted with American Gulf War veter-
ans; therefore these results may not generalize to veterans of other
wars. Additionally, although this was a national sample, results are
not necessarily representative of the population of Gulf war vet-
erans. Third, it is important to account for the fact that our
postdeployment mental health measures were self-report and used
for screening rather than as diagnostic instruments. Despite the fact
that clinically significant cutoff scores have been recommended
for each of these measures, these results should be replicated with
clinician-rated diagnostic tools (e.g., Clinician Administered
PTSD Scale for DSM–IV; Blake et al., 1995). Exposure variables,
including our index of killing, were assessed using a single indi-
cator, and future studies should replicate these results with more
comprehensive measures. This is especially important in order to
better understand which aspects of killing (e.g., circumstances of
killing, person killed, etc.) are associated with increased mental
health problems. However, it is important to note that there is
precedent for examining single exposure items (e.g., LeardMann,
Smith, Smith, Wells, & Ryan, 2009). Although we were able to
index predeployment alcohol use, a limitation is that these reports
were retrospective; additionally we were not able to control for
predeployment PTSD or depression. Future investigations that
utilize broader sets of health and deployment information are
needed to further understand potential mediators and moderators in
this model, such as prior mental health difficulties and prior
Our finding that killing in war is a significant, independent
predictor of multiple mental health symptoms has important im-
plications for the health care of veterans. A comprehensive eval-
uation of veterans returning from combat should include an as-
sessment of killing experiences as well as reactions to killing and
precursors to killing, including witnessing the death of a fellow
soldier and perceived danger, factors that may place veterans at
even greater risk of developing mental health complications such
as PTSD. This information can be used to inform larger conceptual
models of mental health response, as we continue to expand our
understanding of how veterans are impacted by taking a life. For
example, the experience of killing also may be associated with
moral injury (Litz et al., 2009) and changes in spirituality/
religiosity (e.g., Fontana & Rosenheck, 2004). It is critical that
future research examine the broad impact of taking another life in
Overall, we found that a significant percentage of veterans
serving in the Gulf War reported killing, which places them at risk
for PTSD and elevated alcohol use. Including killing experiences
as part of postdeployment evaluation and treatment planning will
ensure that we are providing comprehensive health care to our
modern deployment veterans as they embark on the journey of
reintegration and readjustment to civilian life.
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Hierarchical Regression for Models of Alcohol Use and Problem Alcohol Use
Alcohol use Problem alcohol use
(Step 1) (Step 2) (Final model) R
)(Step 1) (Step 2) (Final model) R
1. Age .01 .03 .01 .07 .01 .02 .04 .09
Gender .16 .17 .13 .09 .08 .04
Ethnicity .01 .02 .05 .16
.16 .13
Education .04 .04 .05 .03 .03 .02
Marital status .15 .16 .15 .16 .17
Prior alcohol use .13 .15 .17
2. Perceived danger .01 .02 .09 (.01) .00 .03 .10 (.01)
Exposure to death .05 .08 .07 .04
Witnessing killing .10 .14 .06 .10
3. Killing .20
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Received August 18, 2009
Revision received March 8, 2010
Accepted March 18, 2010
... Across multiple war eras (Vietnam, Gulf, and Iraq/Afghanistan), being responsible for the death of others has been associated with a PTSD diagnosis and the most severe PTSD symptoms. 21,[26][27][28][29] Furthermore, this association persists after adjusting for other combat exposures. Being responsible for the death of others during combat has also been associated with STBs, demonstrating large effect sizes compared with other types of combat experiences. ...
... Being responsible for the death of others during combat has also been associated with STBs, demonstrating large effect sizes compared with other types of combat experiences. 17,18,28,30 However, whether these findings extend to active-duty soldiers in the post-September 11, 2001 era, [31][32][33] a group whose suicide rates have increased substantially over the past decade, remains relatively unexplored. 34,35 In the current study, we examined the association between responsibility for the death of others in combat and postdeployment mental health outcomes (eg, PTSD, major depressive episode [MDE], STBs, and functional impairment) among active-duty US Army personnel. ...
... These findings replicate and build on the evidence in veterans from multiple war eras that demonstrated an association between being responsible for another's death during combat and subsequent PTSD and STBs. 17,18,21,[26][27][28][29] We found that these associations are detectable while soldiers are still on active duty, which suggests that an opportunity exists for screening and intervention, potentially disrupting the often chronic, treatment-refractory trajectories in veterans with military-related PTSD. 48 In addition, these findings identify the psychological sequelae of being responsible for another's death as a potential intervention target for PTSD psychotherapy at 8 to 9 months postdeployment. ...
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Importance Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others. Objective To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment. Design, Setting, and Participants This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021. Main Outcomes and Measures Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity. Results A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07). Conclusions and Relevance This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.
... Growing evidence in the moral injury literature suggests that we need to expand our framework beyond the traditional fear-based traumatic response that is the focus of existing EBPs for PTSD, to fully address the wounds of war [7]. Despite high rates of killing in war [8] and the associated outcomes [9][10][11][12][13][14], veterans are not routinely assessed for killing experiences. Such assessment could assist with prevention and treatment efforts. ...
... We began by examining the impact of killing through a mixed-method approach. Initial quantitative research examined mental health outcomes associated with killing in war, showing that those who killed in war were at increased risk for posttraumatic stress disorder (PTSD), alcohol abuse, suicide, and functional difficulties after returning home, even after adjusting for the impact of general combat [11][12][13][14]. We found that killing is a unique risk factor that is associated with poor mental health outcomes. ...
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Purpose of Review Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior. Recent Findings In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition. Summary IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.
... Changes can be experienced in the view of the self, relationships with others, and/or worldview and philosophy of life (Tedeschi and Calhoun, 1995;Tedeschi et al., 2018). Studies investigate PTG in various trauma survivors such as war veterans (Maguen et al., 2011), terminal illnesses (Chi et al., 2022), natural disasters (Jia et al., 2017), and accident survivors (Nishi et al., 2010), however, some traumatic experiences such as IPV still receive less attention (Elderton et al., 2017). The dynamics of IPV make it hard to apply the knowledge about PTG from other traumatic contexts. ...
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Increased interest in positive changes in the aftermath of traumatic events led researchers to examine assumptions about the process of posttraumatic growth (PTG). However, existing studies often use samples from mixed trauma survivors and investigate separate factors and their associations with growth. Therefore, the purpose of the current study was to examine the path from centrality of event to PTG involving intrusive and deliberate rumination and self-blame as a coping strategy in women survivors of intimate partner violence (IPV). The study sample consisted of 200 women with a history of IPV (ages 18-69, M = 44.79, SD = 12.94). Results of the path analysis indicated that higher centrality of event was related to higher levels of intrusive rumination which was positively related to self-blame and deliberate rumination eventually leading to PTG. Indirect effects from centrality of event to PTG through intrusive and deliberate rumination, and from intrusive to deliberate rumination through self-blame were examined. This study gave support to some theoretical assumptions of the process of PTG and pointed out problematic areas of investigation of coping strategies in this process.
... It should be noted that although this study focused on the fire service, many of these findings may be applicable to the training and messaging of bullying in other similar occupational groups such as the military and law enforcement, fields that also struggle with bullying (Crowell-Williamson et al., 2019;Farr-Wharton et al., 2017). These fields share many common traits with the fire service including responding to calls for service, intense and stressful work environments, a male-dominated culture, and repeated exposure to trauma (Bartlett et al., 2019;Drummet et al., 2003;Maguen et al., 2011;Pflanz & Sonnek, 2002). In fact, many fire service personnel have a background in the military or law enforcement (Meyer et al., 2012). ...
i>Bullying in the fire service has long been overlooked, although efforts to understand the phenomenon have increased over the past few decades. Recent research has highlighted high rates of bullying in the fire service, regardless of gender and race. Despite established issues of bullying, workplace bullying training has yet to be examined in the fire service. Using qualitative data from interviews with a national sample of firefighters and fire service leaders, this foundational research sought to understand current and future needs related to training on bullying prevention and effective messaging for the fire service. Common themes that emerged from the data include current training opportunities, the effectiveness of training, and components of effective training.</i
... Research indicates providers can meet the needs of this population by being competent in the organizational culture and in military specific mental health issues (Forziat, Arcuri, & Erb, 2018). Some common issues noted by literature unique for this population are Post-traumatic Stress Disorder (PTSD; Ramsey et al., 2017;Judkins et al., 2020), combat related circumstances (Maguen et al., 2011), stressors related to deployments (Booth-Kewley et al., 2010), traumatic brain injury (TBI; Agimi et al., 2019), and military sexual trauma (Wilson, 2018). Previous research offers guidance on best practices to work with this population considering their unique cultural considerations; for instance, reality therapy as it considers the organizational culture (Arcuri Sanders, 2019). ...
p>Licensed counselors are underrepresented as mental health professionals (MHPs) servicing military-connected clients (service member/Veterans and their families). Mixed-methods research, conducted by the authors, highlights key viewpoints of MHPs (counselor, psychologist, and social worker) interested in working with the military and on their level of confidence in working with this population. MHPs’ experiences, perspectives of their profession’s responsibilities to military clients, and their role in comparison to other MHPs is explored. Findings aid in advocacy efforts for the military population to receive counseling from qualified providers and support counseling program development to increase counselor employability among this group.</p
... The concept of moral injury (MI) has inspired and informed a growing body of research on trauma-and stressor-related disorders that follow from events that violate moral beliefs and expectations Wisco et al., 2017; see Griffin et al., 2019 for recent reviews). Although historically focused on combat traumas that involve an element of life threat, violence, or danger to physical integrity, emerging evidence suggests that nonviolent events characterized by a perceived violation of moral beliefs or expectations also may have detrimental consequences (Jordan et al., 2017;Maguen et al., 2011). These potentially morally injurious experiences (PMIEs) share several common elements: PMIEs are deemed as actions or inactions committed either by the self (i.e., perpetration or omission) or others (i.e., transgression or betrayal) that occur in high stakes situations in which a moral value, belief, or expectation is violated through experiencing, witnessing, or learning about the event (Drescher et al., 2011;Farnsworth et al., 2017;Litz et al., 2009;Shay, 2014). ...
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Research on trauma- and stressor-related disorders has recently expanded to consider moral injury, or the harmful psychological impact of profound moral transgressions, betrayals, and acts of perpetration. Largely studied among military populations, this construct has rarely been empirically extended to children and adolescents despite its relevance in the early years, as well as youths’ potentially heightened susceptibility to moral injury due to ongoing moral development and limited social resources relative to adults. Application of the construct to young persons, however, requires theoretical reconceptualization from a developmental perspective. The present paper brings together theory and research on developmentally-oriented constructs involving morally injurious events, including attachment trauma, betrayal trauma, and perpetration-induced traumatic stress, and describes how they may be integrated and extended to inform a developmentally-informed model of moral injury. Features of such a model include identification of potentially morally injurious events, maladaptive developmental meaning-making processes that underlie moral injury, as well as behavioral and emotional indicators of moral injury among youth. Thus, this review summarizes the currently available developmental literatures, identifies the major implications of each to a developmentally-informed construct of moral injury, and presents a conceptual developmental model of moral injury for children and adolescents to guide future empirical research.
Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.
Background: The current study aimed to examine the effects of combat exposure and killing on mental and subjective physical health later in life among Korean Vietnam War veterans.Methods: The data were collected from 342 male veterans with a mean age of 72 years (SD=2.57). Veterans were divided based on their histories into three groups: no experience (Group 1), combat exposure only (Group 2), and both killing and combat exposure (Group 3). Analyses of variance (ANOVAs) examined group differences in post-traumatic stress disorder (PTSD) symptoms, anxiety symptoms, hostility, and perceived physical health.Results: The ANOVAs showed that PTSD, anxiety symptoms and hostility were most prevalent among the veterans in Group 3 (both killing and combat exposure). No significant differences were found between Groups 1 and 2. Perceived physical health was highest among the veterans in Group 1 (no experience). There were no differences between Groups 2 and 3. Even after controlling for the impacts of optimism and social support after homecoming, these results were similar.Conclusions: The findings indicate that killing experience and combat exposure should be considered in designing interventions for veterans deployed into active combat zones.
This study aims to evaluate the key contributing factors of Local Peace Committees in peace�building efforts at conflict-affected areas of Khyber Pakhtunkhwa Pakistan. Data were collected from a sample of 56 respondents through a structured interview schedule using the Likert Scale, and the sample size was calculated through online survey system software. The majority of the LPC members were found to be local elders of advanced age, who belonged to various political parties in the area. Many aspects of the LPCs, such as provision of necessary information and support in identification of militants to state actors, showed a significant relationship with peace-building in the area. The role of LPCs is very vital for peace-building in the area and further research needs to be carried out regarding the issues and problems faced by LPCs in the area.
The association between moral injury and the development of serious social, behavioral, and psychological problems has been demonstrated in a limited but growing body of literature. At present, there is a dearth of evidence pertaining to the mechanism in explaining the relationship between moral injury and posttraumatic stress disorder. This study seeks to examine the serial mediating roles of meaning making and change in situational beliefs in the relationship between moral injury and PTSD. A sample of 737 police officers deployed on fieldwork who have experienced at least one morally injurious event were given psychometric scales assessing moral injury, meaning making, change in situational beliefs, and PTSD. Serial mediation analysis reveals that the positive association between the experience of morally injurious events and PTSD could be accounted for by the decrease in meaning making process and lack of change in situational beliefs. The findings highlight the importance of meaning making and changing situational beliefs in resolving inconsistent thoughts or actions against one’s moral code (i.e., moral injury) that ultimately affects one’s psychological health.
Despite a high prevalence of alcohol-related disabilities and the availability of cost-effective interventions, alcohol abuse and dependence commonly go undetected in hospital inpatients. In a university teaching hospital we compared three well validated screening methods for sensitivity and specificity—the Alcohol Use Disorders Identification Test (AUDIT, with various cut-off scores), CAGE (a four-question screening tool), and a 10-question version of the Michigan Alcoholism Screening Test (BMAST). A subset of patients also completed the DSM IV structured clinical interview for diagnosis. 1133 adult patients were randomly selected from all hospital admissions, with exclusion of day cases and patients too ill to be interviewed. Two-thirds of the patients were interviewed, most of the remainder being unavailable at the time. 30% of the men and 8% of the women met the DSM IV criteria for alcohol abuse or dependence. Sensitivities and specificities of the screening tools were as follows: AUDIT (with cut-off score > 8) 89% and 91%; CAGE 77% and 99%; BMAST 37% and 100%. 255 case records of patients scoring above the cut-off on one or more questionnaires were subsequently reviewed. The admitting team recognized an alcohol problem in only 46, of whom 17 were referred for appropriate follow up. As in previous hospital surveys, alcohol abuse and dependence was not receiving proper attention. The most efficient screening tool was the CAGE questionnaire.
The hypothesis that posttraumatic stress disorder (PTSD) associated with killing is more severe than that associated with other traumas causing PTSD was tested on U.S. government data from Vietnam war veterans. This large stratified random sample, the National Vietnam Veterans Readjustment Study (NVVRS), allows for generalizable findings. Results showed that PTSD scores were higher for those who said they killed compared to those who did not. Scores were even higher for those who said they were directly involved in atrocities compared to those who only saw them. PTSD scores also remained high for those who said they had killed, but in traditional combat form. The data did not support the alternative explanations that higher battle intensity or a predisposition to over-reporting of symptoms might account for these findings.
Four clinical interview questions, the CAGE questions, have proved useful in helping to make a diagnosis of alcoholism. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. The acronym "CAGE" helps the physician to recall the questions.How these questions were identified and their use in clinical and research studies are described.(JAMA 1984;252:1905-1907)
The effectiveness of the Beck Anxiety (BAI-PC) and Depression (BDI-PC) Inventories for Primary Care for discriminating 56 primary care patients (20–77 yrs old) with and without Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) diagnosed anxiety and mood disorders was studied. The Anxiety and Mood modules from the Primary Care Evaluation of Mental Disorders were used to establish diagnoses. The coefficient alphas for the BAI-PC and BDI-PC were, respectively, .90 and .88. A BAI-PC cutoff score of 5 and above yielded the highest clinical efficiency (82%) with 85% sensitivity and 81% specificity for identifying patients with and without panic, generalized anxiety, or both disorders, whereas a BDI-PC cutoff score of 6 and above afforded the highest clinical efficiency (92%) with 83% sensitivity and 95% specificity for detecting patients with and without major depressive disorders. The use of these instruments to screen primary care patients before conducting extensive diagnostic evaluations with them was discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.
A three-group quasi-experimental design contrasted the responses of rescue workers to the 1989 Loma Prieta earthquake Interstate 880 freeway collapse (n=198) with responses to critical incident exposure of Bay Area Controls (n=140) and San Diego Controls (n=101). The three groups were strikingly similar with respect to demographics and years of emergency service. The I-880 group reported higher exposure, greater immediate threat appraisal, and more sick days. The three groups did not differ on current symptoms. For the sample as a whole EMT/Paramedics reported higher peritraumatic dissociation compared with Police. EMT/Paramedics and California road workers reported higher symptoms compared with Police and Fire personnel. Nine percent of the sample were characterized as having symptom levels typical of psychiatric outpatients. Compared with lower distress responders, those with greater distress reported greater exposure, greater peritraumatic emotional distress, greater peritraumatic dissociation, greater perceived threat, and less preparation for the critical incident.
Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.