How Does Moral Injury Affect the Brain in PTSD?

What you need to know

• Moral injury occurs when a person experiences an event that violates their deeply held moral beliefs, potentially leading to PTSD symptoms.
• This study found increased connectivity between emotional brain regions and self-related thinking regions in people with PTSD and moral injury.
• The findings suggest moral injury may impact how people with PTSD process emotions and think about themselves.

Understanding Moral Injury

Moral injury refers to the psychological, social, and spiritual harm that can occur when a person experiences an event that violates their deeply held moral beliefs and expectations. This could involve:

• Doing something that goes against one’s values (an act of commission)
• Failing to prevent something that violates one’s values (an act of omission)
• Witnessing others violate core moral beliefs
• Feeling betrayed by leaders or trusted individuals

While moral injury can occur in various settings, it has been studied extensively in military personnel and veterans. Examples of potentially morally injurious events in a military context include:

• Being ordered to kill civilians
• Failing to provide medical care to all injured individuals in a combat situation
• Freezing up and not performing one’s duty during a critical moment

However, moral injury can also affect other professions that encounter traumatic situations, such as healthcare workers, first responders, and law enforcement. For instance, a doctor may experience moral injury from having to make difficult triage decisions about which patients to prioritize during a disaster.

The Link Between Moral Injury and PTSD

While moral injury and post-traumatic stress disorder (PTSD) are distinct concepts, they often co-occur and have some overlapping symptoms. Key differences include:

• PTSD is characterized by fear-based symptoms like hypervigilance and avoidance
• Moral injury centers more on shame, guilt, and feelings of betrayal
• Not all traumatic events lead to moral injury
• It’s possible to experience moral injury without developing full PTSD

However, moral injury can increase the risk of developing PTSD and exacerbate symptoms. The intense emotions and self-reflection involved in moral injury may compound the effects of trauma.

How Moral Injury Affects the Brain

This study used functional magnetic resonance imaging (fMRI) to examine brain activity in three groups:

1. People with military/law enforcement-related PTSD and moral injury
2. People with civilian-related PTSD and moral injury
3. Healthy controls who experienced a potentially morally injurious event but did not develop PTSD

Participants recalled a morally injurious event while in the fMRI scanner. The researchers analyzed connectivity between different brain regions, focusing on:

• The default mode network (DMN): A set of brain regions active when we’re engaged in self-reflection, autobiographical memory, and thinking about others
• Midbrain regions: Areas involved in basic emotion processing and bodily sensations

Key findings:

• Both PTSD groups showed increased connectivity between the midbrain (specifically the periaqueductal gray) and regions of the DMN compared to healthy controls
• The civilian PTSD group also had increased connectivity between the cerebellum and DMN

What This Means for Understanding PTSD and Moral Injury

These results suggest that in people with PTSD and moral injury, there is increased communication between brain areas involved in intense emotions/bodily sensations and areas involved in self-reflection and memory.

This may help explain why people with PTSD often experience:

• Intrusive memories with strong emotional and physical reactions
• Difficulty processing the morally injurious event
• Persistent feelings of shame and self-blame
• Challenges with self-identity and relating to others

The increased midbrain-DMN connectivity could represent a “hijacking” of self-related thinking by intense emotions and survival instincts. This may make it harder for people with PTSD to think about themselves and their experiences in a balanced way.

Implications for Treatment

Understanding how moral injury impacts brain functioning in PTSD could lead to more targeted treatments. The researchers suggest:

1. Incorporating “bottom-up” therapy approaches that address physical and emotional reactions, not just thoughts. Examples include:

   • Sensorimotor therapy
   • Deep brain reorienting
   • Neurofeedback

2. Combining these with traditional “top-down” cognitive therapies for a more holistic approach

3. Focusing on processing shame and guilt related to moral injury as a key part of PTSD treatment

4. Developing interventions to help regulate the connection between emotional/bodily processes and self-reflection

Conclusions

• Moral injury appears to impact brain functioning in PTSD by increasing connectivity between emotional and self-related regions
• This may explain why moral injury can intensify PTSD symptoms and make recovery more challenging
• Treatment approaches that address both “bottom-up” emotional/physical processes and “top-down” thinking patterns may be most effective for PTSD with moral injury

While more research is needed, this study provides important insights into how moral wounds impact the brain, potentially leading to more targeted and effective treatments for PTSD in the future.